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A 


CLINICAL  TREATISE 


ON 


FRACTURES 


BY 

WILLIAM  BARTON   HOPKINS,  M.  D. 

Surgeon  to  the  Pennsylvania  Hospital,  and  to  the  Orthopedic  Hospital 
and  Infirmary  for  Nervous  Diseases 


PHILADELPHIA 

J.   B.   LIPPINCOTT  COMPANY 

i  goo 


Copyright,  1900, 
By  J.  B.  LIPPINCOTT  COMPANY. 


PREFACE. 


As  the  title  indicates,  the  intention  of  this  work  is  to 
treat  the  subject  of  Fractures  in  its  clinical  aspect.  The 
matter  presented  is,  in  fact,  a  report  of  unpublished  clini- 
cal lectures  delivered  by  the  author  at  the  Pennsylvania 
Hospital,  so  revised  and  elaborated  as  to  eliminate  the 
elements  of  incompleteness  of  clinical  delivery  and  lack 
of  method  necessarily  incident  to  utilizing  clinical  material. 
The  many  details,  too,  of  individual  cases  which  may  prof- 
itably be  referred  to  in  a  clinical  lecture  have  been  gener- 
ally omitted.  It  has  also  been  thought  desirable  to  avoid 
the  restating  of  traditions  which  have  become  obsolete,  the 
recording  of  statistics,  and  the  formulating  of  methods  of 
treatment  long  since  abandoned;  for,  while  such  historical 
matter  seems  inseparable  from  a  work  of  reference,  it  is 
not  essential  in  a  treatise  intended  for  practical  use.  In 
the  matter  of  the  management  of  fractures  it  may  be  stated 
that  while  at  times  a  choice  between  several  methods  is 
given,  the  author  usually  advises  that  form  of  treatment 
which  in  his  own  experience  has  proved  most  simple  and 
effective. 

The  skiagraphs  reproduced  have  been  selected  from 
a   great    number    taken    at   the    Pennsylvania    Hospital   by 


4  PREFACE. 

Drs.  Starbuck  and  Stewart.  The  illustrations  of  fractured 
bones  are  from  specimens  in  the  Mutter  Museum  of  the 
College  of  Physicians,  and  the  Museum  of  the  Pennsyl- 
vania Hospital.  To  the  pathologist  of  the  latter,  Dr. 
H.  W.  Cattell,  the  author  owes  his  thanks  for  many  pho- 
tographs. 


CONTENTS. 


CHAPTER   I. 

PAGE 

INTRODUCTION 9 


CHAPTER   II. 

FRACTURES  OF  THE  UPPER  EXTREMITY 25 

Fractures  of  the  Hand 25 

Phalanges 25 

Metacarpal  Bones 28 

Carpal  Bones 33 

Fractures  of  the  Forearm ■ 33 

Fractures  of  the  Radius 33 

Fractures  of  the  Ulna 51 

Fractures  of  the  Shafts  of  the  Radius  and  Ulna 61 

Fractures  of  the  Humerus 67 

Fractures  of  the  Lower  End  of  the  Humerus 68 

Fractures  of  the  Shaft  of  the  Humerus 77 

Fractures  of  the  Upper  Extremity  of  the  Humerus 83 

Fractures  of  the  Scapula 94 

Fracture  of  the  Body  of  the  Scapula 94 

Fracture  of  the  Coracoid  Process  of  the  Scapula 95 

Fracture  of  the  Acromion  Process  of  the  Scapula 96 

Fractures  of  the  Clavicle 98 

CHAPTER   III. 

FRACTURES  OF  THE  LO^YER  EXTREMITY 106 

Fractures  of  the  Foot 106 

Fractures  of  the  Phalanges 106 

Fractures  of  the  Metatarsal  Bones 107 

Fractures  of  the  Tarsus 109 

5 


6  CONTENTS. 

PAGE 

Fractures  of  the  Leg 114 

Fractures  of  the  Tibia 114 

Fractures  of  the  Fibula 118 

Fractures  of  both  Bones 122 

Fractures  of  the  Patella   131 

Fractures  of  the  Femur  .    .- 147 

Fractures  of  the  Shaft 148 

Fractures  of  the  Upper  Extremity  of  the  Femur 152 

Fractures  of  the  Lower  Extremity  of  the  Femur 156 

CHAPTER  IV. 

FRACTURES  OF  THE  PELVIS 169 

Fractures  of  the  Ilium 169 

Fractures  of  the  Pubis.    .' 170 

Fractures  of  the  Ischium 171 

Fractures  of  the  Acetabulum 171 

CHAPTER   V. 

FRACTURES  OF  THE  STERNUM  AND  RIBS 174 

Fractures  of  the  Sternum 174 

Fractures  of  the  Ribs 176 

CHAPTER  VI. 

FRACTURES  OF  THE  SPINE 182 

Fractures  of  the  Spinous  Processes 188 

Fractures  of  the  Laminae 189 

Fractures  of  the  Bodies  of  the  Vertebra 191 

CHAPTER  VII. 
FRACTURES  OF  THE  SKULL 201 

CHAPTER  VIII. 

FRACTURES  OF  BONES  OF  THE   FACE 228 

Fractures  of  the  Nose 228 

Fractures  of  the  Upper  Jaw 230 


CONTENTS.  7 

PAGE 

Fractures  of  the  Malar  Bone 231 

Fracture  of  the  Zygoma 232 

Fractures  of  the  Lower  Jaw 232 

Fractures  of  the  Hyoid  Bone 237 


CHAPTER  IX. 
COMPOUND  FRACTURES 238 


CLINICAL  TREATISE  ON  FRACTURES. 


CHAPTER   I. 
INTRODUCTION. 


In  reviewing  the  clinical  history  of  fractures,  their  causes, 
predisposing  and  direct,  may  first  be  considered.  Of  the 
predisposing  causes,  age,  sex,  occupation,  and  constitu- 
tional conditions  (including  diseases  and  peculiarities  of  the 
osseous  system)  are  the  principal. 

Age  influences  the  occurrence  of  fractures  in  many  ways. 
The  friability  of  the  bones  in  young  persons  and  their  brittle- 
ness  in  the  aged  more  than  offset  the  comparatively  pro- 
tected conditions  in  which  they  live.  The  many  statistics 
which  have  been  collected  show  that  between  the  ages 
of  sixty  and  eighty  there  is  a  larger  proportion  of  fract- 
ures than  at  any  other  equal  period  of  life. 

During  adult  life  fractures  occur  with  greater  frequency 
in  the  male  sex  than  in  the  female,  because  of  the  more 
exposed  life  led  by  the  former.  In  infancy  and  early 
childhood  there  is  little  difference  in  the  relative  frequency. 
Occupation  largely  affects  the  occurrence  of  fractures. 
Persons  who  lead  lives  of  activity  and  hard  work  are,   for 


IO  A    CLINICAL    TREATISE    OX  FRACTURES. 

very  obvious  reasons,  more  likely  to  suffer  them  than  those 
engaged  in  sedentary  occupations. 

Certain  diathetic  diseases  predispose  their  subjects  to 
fracture,  because  of  the  increased  brittleness  of  the  skele- 
ton incident  upon  them.  Height  is  also  a  predisposing 
cause,  as  long  bones  are  relatively  more  liable  to  fracture 
than  short  ones. 

The  direct  cause  may  be  briefly  and  pertinently  described 
as  force.  The  long  bones  yield  to  force  applied  in  three 
distinct  ways :  (i)  direct  force,  (2)  indirect  force,  and  (3) 
muscular  force. 

(1)  Direct  force,  often  called  direct  impact,  causes  fract- 
ure by  the  transverse  strain  to  which  the  bone  is  subjected, 
as  a  plank  supported  at  its  ends  breaks  when  stood  upon. 
Direct  force  may  also  crush  the  bone  if  resistance  is  met 
with  beneath,  as  when  a  car-wheel  passes  over  a  limb;  or 
direct  force  may  puncture  or  shatter  the  bone,  as  in  gun- 
shot fracture. 

(2)  Indirect  force  causes  fracture  by  the  end-on-end  strain 
applied  to  the  bone,  whether  this  strain  be  produced  by  press- 
ure exerted  at  both  of  its  ends,  as  when  the  femur  is  fract- 
ured by  compressing  forces  acting  between  the  hip  and  the 
knee,  or  by  the  impact  resulting  from  a  fall  when  the 
resistance  of  the  ground  is  equivalent  to  one  force  and  the 
weight  of  the  body  is  the  other. 

(3)  Muscular  Force. — The  contraction  of  a  muscle  may 
fracture  a  bone  by  direct,  indirect,  or  by  tensile  force,  accord- 
ing to  the  point  of  insertion  and  mode  of  action  of  the  mus- 
cle.    If  its  contraction  causes  a  transverse  strain    upon  the 


INTR  OD  UCTION.  1 1 

shaft  of  the  bone,  the  force  will  be  seen  to  be  in  all  respects 
similar  to  that  of  direct  impact,  except  that  it  operates  by 
traction  instead  of  impact, — the  clavicle  may  be  fractured 
in  this  way.  Should  the  insertion  of  the  muscle  and  its 
origin  act  on  the  extremities  of  the  bone,  the  force  is 
indirect,  and  the  bone  yields  from  a  bending  or  crushing 
strain.  Fracture  of  the  humerus  from  muscular  violence 
is  thus  produced.  The  tensile  strain  exercised  by  mus- 
cular contraction  is  most  prominently  illustrated  by  fract- 
ure of  the  patella;  but  it  also  operates  in  every  instance 
in  which  a  large  or  small  fragment  of  a  bone  is  torn  off 
by  the  tendon  attached  to  it,  as  from  the  os  calcis  or  olec- 
ranon. 

The  measure  of  force  required  to  break  a  bone  depends 
not  only  upon  the  advantage  or  disadvantage  under  which 
such  force  operates,  but  also  upon  the  resistance  offered  by 
the  bone.  The  former  is  influenced  by  mechanical  condi- 
tions too  varied  to  formulate.  The  latter  in  average  skele- 
tons is  determined  by  age  and  other  conditions  above 
referred  to.  The  younger  the  bone,  the  more  flexible  it  is ; 
the  older  the  bone,  the  more  brittle.  Bone,  during  infancy 
and  youth,  though  flexible,  is  friable;  and  it  steadily 
increases  in  strength  until  about  the  age  of  thirty  years, 
when  the  maximum  is  reached.  While  we  have  little  data 
upon  which  to  base  any  definite  conclusion  regarding  it, 
the  period  of  maximum  strength  lasts  perhaps  for  ten  years. 
Its  gradual  diminution  in  strength  results  from  increased 
brittleness  which  finally  in  old  age  once  again  renders  it 
friable.      Young   bone    bends   very    much  before  it  breaks; 


12  A    CLINICAL    TREATISE    ON  FRACTURES. 

but  it  must  be  borne  in  mind  that  old  bone  also  bends 
before  it  breaks,  however  brittle  it  may  be.  "The  limit 
of  stiffness  is  flexure,  and  the  limit  of  strength  or  resist- 
ance is  fracture."  If  a  bone  is  bent  within  the  limit 
of  its  elasticity,  it  springs  back  to  its  normal  axis  and 
leaves  no  trace  of  the  strain  to  which  it  has  been  subjected. 
As  this  limit  in  the  young  bone  is  wide,  it  may  frequently 
be  demonstrated  while  performing  osteoclasis,  by  relaxing 
the  pressure  of  the  instrument.  A  strain  beyond  the  limit 
of  elasticity  produces  in  young  bone  a  kink,  a  greenstick 
fracture,  or  an  incomplete  fracture ;  but  these  conditions 
occur  with  diminishing  frequency  as  the  age  of  the  bone 
increases. 

The  actual  force  in  pounds  required  to  fracture  adult 
bone  is  of  sufficient  interest  to  have  suggested  the  perform- 
ance of  a  series  of  experiments  with  the  well-known  testing- 
machines  of  Messrs.  Riehle  Brothers.  For  this  purpose, 
various  bones  recently  removed  from  a  strong  male  adult 
mulatto,  twenty-seven  years  of  age,  who  had  died  of  an 
acute  disease,  were  selected  as  best  representing  the  average 
full-grown  skeleton.  The  strains  applied  by  the  appropri- 
ate testing-machines  were  transverse,  crushing,  and  tensile. 

Transverse  force,  which,  as  stated  above,  corresponds  to 
direct  impact,  was  applied  to  the  femur,  and  the  tibia  and 
fibula;  crushing  force,  corresponding  to  indirect  force,  was 
applied  to  the  femur,  tibia  and  fibula,  and  to  the  humerus ; 
and  tensile  strain  was  tested  on  the  patella. 

The  bones,  having  been  properly  protected  with  padding, 
were  subjected    to  the  various  strains  as  follows  :    the    left 


INTR  OD  UCTION. 


13 


femur  yielded  to  a  transverse  strain  of  11 55  pounds,  causing, 
as  shown  in  Fig.  1,  a  transverse  fracture  in  its  middle  third; 


Fig.  i. 


the     right    tibia     and     fibula  FlG- 2 

yielded  to  a  transverse  strain 
of  1 1 15  pounds,  with  a  trans- 
verse fracture  at  the  junction 
of  the  middle  with  the  lower 
third  of  the  former,  and  a 
transverse  fracture  at  the  junc- 
tion of  the  middle  with  the 
upper  third  of  the  latter,  as 
shown  in  Fig.  2. 

A  crushing  strain  of  3130 
pounds  applied  to  the  right 
femur  caused  it  to  yield  at  its 
middle  third,  with  a  slightly 
oblique  fracture,  as  shown  in 
Fig.  3,  but  not  before  it  had 
bent  twenty  degrees  from  its 
axis.  A  crushing  strain  ap- 
plied to  the  left  tibia  and 
fibula  caused  an  oblique  fracture  in  the  upper 
middle  third  of  the  former,  and  a  transverse 
fracture  in  the  lower  middle  third  of  the  lat- 
ter, at  2270  pounds  (Fig.  4).  A  crushing  strain  produced  a 
transverse  fracture  of  the  right  humerus  in  its  lower  third  at 
a  pressure  of  2530  pounds  (Fig.  5).  Tensile  strain,  that  cor- 
responding to  muscular  action  in  causing  fracture  of  the 
patella,  was  tested  upon  that  bone,  with  the  result  that  the 


Tibia  and  fibula 
fractured  by  a 
transverse  strain 
of  1115  pounds. 


Femur  fractured 
by  a  transverse 
strain  of  1155 
pounds. 


14 


A    CLIXICAL    TREATISE    OX  FRACTURES. 


Fig.  3. 


Fig.  4. 


ligament  of  the  patella  was  ruptured  about  its  middle,  but 
no  damage  was  done  to  the  patella  itself,  at  1845  pounds. 
The  results  of  these 
several  tests,  particu- 
larly the  crushing  ones, 
those  applied  end-on- 
end,  appear  remarkable, 
but  as  their  accuracy 
is  unquestioned,  they 
must  be  accepted.  That 
the  bones  yielded  only 
to  such  enormous 
strains  is  to  be  ex- 
plained by  the  fact  that 
the  pressure  was  ap- 
plied gradually.  A 
bone  is  almost  invari- 
ably fractured  by  sud- 
denly applied  force  and 
rarely  by  one  which 
moves  almost  imper- 
ceptibly, as  did  those 
applied  by  the  testing-machines.  The 
impact  of  a  tack-hammer,  light  as  the 
latter  is,  has  its  value  in  pounds,  and 
that  a  sufficient  weight  superimposed  upon  a  tack  will  drive 
it  is  obvious.  Rapidity  of  impact,  therefore,  momentum, 
and  leverage  are  all  factors  in  causing  fracture.  But,  as 
above  stated,   to  formulate  their  modes  of  operating  would 


Tibia  and  fibula  fract- 
ured by  a  crushing 
strain  of  2270 
pounds. 


Femur  (posterior  view) 
fractured  by  a  crush- 
ing strain  of  3130 
pounds. 


INTR  OD  UCTION.  I  5 

be  too  complex  a  problem  to  state.  As  the  bones  were  fresh 
and  had  not  dried  out  at  all,  they  presumably  had  neither 
•lost  nor  gained  strength  by  being  dead.     That 

r  IG.  5- 

neither  the  femur  nor  the  humerus  is  an  erect        40fc«> 
cylinder,  but  each  possesses  a  curve  which  mate- 
rially lessens  its  vertical  strength,  may  also  be 
noted. 

That  the  pressure  of  over  half  a  ton  applied 
transversely  was  required  to  break  the  femur, 
and  of  nearly  half  a  ton  to  break  the  tibia  and 
fibula,  is  also  remarkable,  while  the  tensile 
strain  of  1845  pounds  which  failed  to  break  the 
patella  has  an  interesting  bearing  upon  the 
fracture  of  this  bone  by  muscular  action.  The 
actual  power,   however,   exerted  by  muscles   in  /.       \ 

performing  the  various  movements  of  the  body,     jM~„,       1 

r  per* 
acting  as  they  usually  do  upon  levers  of  great        ?    w*  ' 

Humerus     fract- 

disadvantage,  is  far  greater  than  has  been  attrib-    uredbyacrush- 
uted  to  them.     This  fact  has  been  demonstrated    ins  strain  of 
by  the  author  in  a  series  of  studies  based  upon 
the  relations  between  fulcrum,  power,  and  weight  in  execut- 
ing certain  movements  of  the  arm. 

The  processes  of  repair  by  which  the  fracture  unites, 
belonging  as  they  do  to  surgical  pathology  rather  than  to 
clinical  study,  need  not  be  referred  to. 

The  varieties  of  fractures  may  be  classified  as  : 
Simple  fracture,  which  signifies  the  loss  of  continuity  of 
a  bone  unaccompanied  by  other  injury.     The  term  is  used 
especially  in  contrast  with  compound  fracture. 


1 6  A    CLINICAL    TREATISE    ON  FRACTURES. 

Compound  fracture,  one  communicating  with  the  exterior 
through  a  wound. 

Comminuted  fracture,  where  a  bone  is  broken  into  three 
or  more  fragments. 

Fissured  fracture,  where  a  line  of  fracture  or  crack 
FlG  6  extends  through  a  bone  in  such  a  manner  that 
it  does  not  destroy  the  continuity  of  the  latter. 
Multiple  fracture  indicates  the  presence  of 
two  or  more  separate  seats  of  fracture,  as  shown 
in  Fig.  6. 

Complicated  fracture  is  a  term  with  a  wide 
range  of  significance,  used  to  denote  the  coex- 
istence with  the  fracture  of  some  other  injury 
likely  to  interfere  with  the  proper  course  of  the 
latter.  It  is  too  indefinite  a  term  to  be  of 
much  use. 

Punctured  Fracture. — The  penetration  into  a 
bone  of  a  substance  which  either  causes  a  fract- 
ure along  the  course  it  travels,  or,  by  the  vio- 
lence of  its  impact,  one  which  radiates  in  various 
directions,  may  be  described  as  a  punctured 
Multiple  fract-  fracture.  The  commonest  form  of  such  is  gun- 
emur.  ^^  fracture,  presently  to  be  referred  to ;  but 
not  infrequently  a  horseshoe,  cotton-hook,  pick-axe,  or  knife 
is  driven  into  a  bone,  causing  a  puncture  of  the  latter. 
A  fracture  thus  produced  is  always  compound,  and,  owing 
to  the  liability  of  the  introduction  of  material  which  causes 
infection  and  consequent  necrosis,  is  one  which  requires 
particular  attention,  thorough  cleansing,  and  perfect  drain- 


INTR  OD  UCTION.  I J 

age.  Two  remarkable  instances  of  such  fracture  have 
come  to  my  notice,  one  under  the  care  of  a  colleague, 
the  other  under  my  own  care.  An  ordinary  penknife- 
blade  was  driven  through  the  parietal  bone  of  an  adult 
into  the  brain.  Breaking  off  flush  with  the  surface  of  the 
skull,  it  not  unnaturally  escaped  detection  for  some  time. 
When  its  presence  was  discovered  it  was  extracted  by  tre- 
phining. Later,  serious  cerebral  symptoms  suggested  further 
exploration,  and  revealed  an  extensive  brain  abscess,  which 
proved  fatal.  The  other  was  the  case  of  a  man  who  had 
received  multiple  stab-wounds  of  the  back.  He  had  been 
under  treatment  several  days  before  a  well-defined  promi- 
nence was  observed  beneath  the  integument  of  the  right 
shoulder.  An  incision  revealed  the  presence  of  a  large  knife- 
blade  embedded  for  nearly  its  entire  length  in  the  head  of 
the  humerus.  It  was  then  ascertained  that  while  the  man 
was  being  stabbed  he  had  clutched  the  back  of  his  neck 
with  his  clasped  hands.  In  the  final  thrust  made  in  the 
shoulder  the  knife  had  entered  the  extremely  rotated  head 
of  the  humerus,  and  had  broken  off;  the  arm,  in  resuming 
its  natural  position,  had  carried  the  blade  to  a  point  far  ante- 
rior to  the  small  wound  of  the  integument  through  which  it 
had  entered.  It  is  interesting  to  mention  that  a  perfect 
reproduction  of  the  cancellous  structure  of  the  bone  was 
etched  on  the  bright  steel  surface.  The  punctured  wound 
of  the  humerus  in  this  case  healed  without  suppuration. 
Punctured  fractures  occurring  along  the  anterior  surface 
of  the  tibia  are  those  most  likely  to  be  followed  by  necro- 
sis.    While  it    may  often  be  limited  and   trivial,   at  times. 


1 8  A    CLINICAL    TREATISE    ON  FRACTURES. 

through  an  infectious  osteitis,  it  becomes  extensive.  The 
treatment  of  punctured  fracture  is  similar  to  that  of  other 
forms  of  compound  fracture. 

Gunshot  Firactures. — Fractures  produced  by  projectiles  of 
either  small  or  large  arms  are  generally  described  as  gunshot 
fractures.  They  include,  therefore,  fractures  produced  by 
the  discharge  of  pistols,  rifles,  shotguns  at  short  range,  and 
the  various  machine-guns.  The  characteristic  phenomena 
of  the  gunshot  fractures  commonly  met  with  in  civil  practice, 
and  often  caused  by  pistols  of  small  or  large  calibre  but  low 
power,  differ  widely  from  those  in  military  surgery,  especially 
since  the  very  general  adoption  of  army  rifles  of  small  calibre 
but  high  power.  The  extent  of  damage  done  to  a  bone 
by  a  ball  is  in  direct  proportion  to  the  size  of  the  latter 
and  in  inverse  ratio  to  its  velocity.  The  large  ball  at  low 
velocity  shatters  the  bone;  while  the  small  ball  at  high 
velocity,  generally  speaking,  bores  a  round  hole  through 
it,  and  perhaps  does  nothing  more.  The  physical  effects 
upon  the  bone  of  gunshot  fractures  are  various.  The  ball 
may  merely  graze  it,  may  splinter  a  fragment  from  it, 
may  bore  a  hole  through  it,  may  cause  loss  of  continuity 
with  more  or  less  comminution,  as  shown  in  Fig.  7,  or  may 
completely  shatter  it,  as  shown  in  Fig.  8.  The  fracture 
thus  produced,  whatever  its  other  characters  may  be,  is 
inevitably  a  compound  fracture.  If  the  wound  of  entrance 
is  near  the  seat  of  fracture,  the  conditions  present  closely 
resemble  those  of  compound  fracture  otherwise  produced. 
On  the  other  hand,  if  it  be  remote,  the  compound  wound  is 
not  only  long,  but,  owing  to  the  probable  alteration  incident 


INTR  OD  UCTION. 


19 


Gunshot  fract- 
ure of  the 
humerus. 


to  changes  in  the  position  of  the  limb  in  the  relation  of 
skin  to  fascia,  fascia  to  muscles,  and  muscles  to  bone,  it  is 
fig.  7.        also  tortuous,  and  communication  fig.  8. 

between  the  wound  of  entrance 
and  the  seat  of  fracture  is  thereby 
cut  off.  The  effect  of  such  ob- 
literation of  the  compound  wound 
is  either  the  fortunate  and  imme- 
diate conversion  of  the  fracture 
into  a  simple  fracture,  or,  should 
any  source  of  infection  have 
reached  it,  suppuration  of  an  ex- 
tremely insidious  character. 

The  diagnosis  of  gunshot  fract- 
ure rests,  first,  upon  the  existence  of  a  gun- 
shot wound ;  and,  secondly,  upon  whether 
the  missile  inflicting  the  latter  has  damaged 
the  bone.  The  presence  of  the  gunshot 
wound  having  been  determined,  a  bone  lesion  Gunshot  fracture  of 

.  the  femur. 

may  be  perfectly  patent  or  its  detection  may 
require  careful  investigation.  If  not  directly  beneath  the 
wound  of  entrance,  the  fracture  may  be  demonstrated  by  the 
ordinary  signs  of  fracture, — mobility,  crepitus,  and  deform- 
ity; or  its  presence  may  be  revealed  by  a  probe  or  in  the 
course  of  dissection  incident  to  exploration  for  the  ball. 

The  treatment  of  gunshot  fractures,  apart  from  the  fract- 
ure, is  based  upon  the  general  management  of  gunshot 
wounds, — to  locate  and  if  possible  extract  the  ball.  The 
presence  and   location  of  the  ball,   at  a  point  remote  from 


20  A    CLINICAL    TREATISE    ON  FRACTURES. 

the  wound  of  entrance,  if  superficial,  are  not  infrequently 
shown  by  a  small  blue  point  of  ecchymosis  of  the  integu- 
ment. This  spot  pressed  upon  will  be  found  tender,  and 
the  ball  may  at  times  be  felt.  The  silver  probe  tipped  with 
porcelain — Nelaton's  probe — will  occasionally  reveal  the  pres- 
ence of  the  ball;  but  it  and  all  similar  methods  have  to  a 
great  extent  been  abandoned  for  the  definite  and  graphic 
demonstration  furnished  by  the  Roentgen  apparatus.  With  it 
the  presence  and  position  of  bullets  in  either  upper  or  lower 
extremities  can  in  most  cases  be  determined  with  sufficient 
accuracy  to  enable  the  surgeon  to  cut  down  directly  upon 
them.  If  the  ball  is  removed,  the  management  of  the  fract- 
ure may  be  proceeded  with  as  with  a  compound  fracture 
otherwise  produced. 

Delayed  union  and  ununited  fracture  result  from  either 
local  causes  affecting  the  conditions  at  the  seat  of  fracture,  or 
from  constitutional  tendencies  or  diseases  which  act  locally 
in  retarding  or  preventing  union.  The  chief  local  causes 
are  imperfect  fixation,  unreduced  deformity,  the  intrusion 
between  the  fragments  of  a  tendon  or  band  of  fascia,  necro- 
sis, and,  rarely,  the  development  of  malignant  disease,  such 
as  osteosarcoma.  Imperfect  fixation  is,  in  my  opinion,  by 
far  the  most  frequent  cause,  but  it  is  by  no  means  always 
preventable.  Certain  fractures  cannot  by  the  use  of  any 
device  be  kept  at  rest  if  muscular  contractions,  voluntary  or 
involuntary,  which  disturb  them  are  persisted  in.  Any  con- 
stitutional disease  which,  by  weakening  the  osseous  system 
predisposes  to  fracture,  is  liable  to  retard  or  prevent  union 
after  fracture  because  of  the  deficiency  in  the  processes  of 


INTR  OD  UCTION.  2 1 

repair  associated  with  it.  Ununited  fracture,  therefore,  fre- 
quently occurs  in  rachitic  and  syphilitic  subjects,  and  some- 
times in  those  with  osteomalacia. 

Ununited  fracture  is,  fortunately,  far  less  common  than 
formerly;  particularly  is  this  true  of  fractures  of  the  leg, 
Improved  results  in  fractures  of  the  tibia  and  fibula  are  prob- 
ably largely  attributable  to  the  almost  universal  employment 
of  plaster-of-Paris  or  other  fixed  dressings.  The  very  general 
use,  too,  of  the  Roentgen  apparatus  to  inspect  with  the 
fluoroscope,  and,  if  necessary,  to  photograph  the  seat  of 
fracture  before  and  after  its  reduction  has  been  attempted, 
has  certainly  been  of  benefit  in  securing  more  perfect  coap- 
tation of  fragments,   and  consequently  their  early  union. 

The  treatment  of  delayed  union  may  be  briefly  stated  as 
prolonged  fixation.  When  the  failure  to  unite  continues  and 
is  evidently  uninfluenced  by  prolonged  fixation,  the  fracture 
may  properly  be  called  ununited.  When  the  condition  char- 
acterizing delayed  union  gives  place  to  that  of  ununited 
fracture  some  special  management  of  the  case  becomes  neces- 
sary. Rubbing  the  fragments  forcibly  together,  by  provok- 
ing irritation  and  congestion  of  them,  may  occasionally 
effect  something  in  the  way  of  a  renewed  effort  at  the  repara- 
tive process.  If  of  a  bone  of  the  lower  extremity,  some  form 
of  apparatus  may  be  applied,  which,  while  giving  fixation, 
will  permit  the  use  of  the  limb,  and  will  by  means  of  this 
use  tend  to  excite  the  exudation  of  reparative  material.  To 
the  same  end  the  fragments  may  be  drilled  in  various  direc- 
tions, with  thorough  aseptic  precautions  against  infection, 
for,  while  the  object  of  the  drilling  is  to  produce  inflamma- 


22  A    CLINICAL    TREATISE    ON  FRACTURES. 

tion,  the  inflammation  should  be  wholly  traumatic  and  non- 
infectious. Never  very  satisfactory,  these  various  methods  of 
temporizing  with  ununited  fractures  have  fallen  into  disuse, 
because  more  radical  operations,  which  formerly  were  dan- 
gerous, have,  through  present  surgical  technique,  become 
comparatively  safe.  Any  fracture  which  has  failed  to  unite 
after  three  months  of  careful  treatment  may  be  regarded  as  a 
proper  one  upon  which  to  perform  some  operation.  Whether 
the  defect  is  in  the  forearm,  arm,  leg,  or  thigh,  the  operation 
consists  of  exposing  by  a  vertical  incision  and  dissection  the 
site  of  fracture,  isolating  the  fragments  from  their  closely 
adherent  surroundings,  and,  after  freshening  their  ends, 
uniting  them  by  some  form  of  suture.  The  ends  may  be 
scarfed  or  drilled,  if  the  length  of  the  bone  is  not  already 
too  much  lessened  to  warrant  further  shortening.  The 
scarf-joint,  united  by  the  single  screw,  a  method  which 
will  be  described  in  the  treatment  of  compound  fractures, 
would  appear  best  suited  for  the  tibia,  femur,  and  humerus. 
I  have  not,  however,  had  the  opportunity  to  use  it  for 
ununited  fractures.  After  suture  by  wire,  silkworm-gut, 
pins,  or  screws,  the  case  is  managed  in  all  respects  as  is 
a  recent  compound  fracture  similarly  dealt  with. 

The  Treatment  of  Fractures. — The  essential  ele- 
ments in  the  treatment  of  fractures  are  reduction  and  fixa- 
tion. By  reduction  is  meant  the  restoration  of  the  broken 
fragments  as  accurately  as  possible  to  their  natural  relation 
to  one  another :  the  object  is  to  make  them  fit  as  nearly  as 
possible.  This,  like  the  process  of  modelling,  may  often 
be  done  by  simple  manipulation,  by  which   the  fragments 


INTRODUCTION.  23 

can  readily  be  moved  about  until  they  are  felt  to  be  in 
proper  position  and  the  normal  contour  of  the  part  is  ob- 
served to  be  restored.  Such  manipulation  requires  practice 
and  dexterity,  while  the  correct  idea  of  form  necessary  to  the 
full  appreciation  of  contour  would  seem  to  be  intuitive, — 
possessed  by  some  without  education,  denied  to  others  in 
spite  of  it.  Reduction  may  be  facilitated  by  the  postural 
relaxation  of  certain  muscles ;  it  may  be  difficult,  requiring 
the  exercise  of  force,  as  in  greenstick  or  impacted  fractures, 
or  it  may  be  painful,  necessitating  the  use  of  an  anaesthetic 
for  its  accomplishment.  Should  the  fracture  resist  reduc- 
tion, it  is  said  to  be  refractory,  and  then  other  means  than 
manipulation,  force,  and  anaesthesia  must  be  resorted  to 
in  order  to  bring  the  fragments  into  proper  apposition. 
As  refractory  fractures  are  more  commonly  met  with  in 
those  which  are  compound,  their  management  will  be  de- 
scribed under  the  treatment  of  the  latter.  Fixation  signifies 
the  retention  in  a  state  of  immobility  of  the  broken  frag- 
ments of  bone  until  they  have  united.  It  may  be  obtained 
in  a  variety  of  ways  :  for  some  fractures,  rest  in  the  recum- 
bent posture  alone  is  sufficient  ;  while  for  others,  some 
form  of  dressing,  apparatus,  or  splint  is  necessary  to  accom- 
plish the  result.  Whatever  the  appliance  may  be,  the 
greatest  care  and  most  constant  watchfulness,  both  in  its 
manner  of  application  and  in  noting  the  effects  it  produces 
upon  all  the  tissues  concerned,  are  necessary.  Damage  to 
the  integument  from  pressure  of  splints,  compresses,  or  dress- 
ings not  only  inflicts  needless  discomfort  upon  the  patient, 
but    seriously    embarrasses   the   treatment   of    the    fracture. 


24  A    CLINICAL    TREATISE    ON  FRACTURES. 

Too  tight  a  bandage  may,  if  it  does  nothing  more,  cause 
a  cellulitis  which  will  retard  recovery  or  perhaps  interfere 
with  the  ultimate  restoration  to  function  of  the  part ;  or  it 
may  cause  pressure  paralysis.  As  in  fractures  of  the  extrem- 
ities, fixation  of  the  fragments  can  be  made  complete  only 
by  retaining  the  adjacent  joints  in  a  state  of  immobility, 
to  guard  against  permanent  rigidity  of  these  joints,  partic- 
ularly if  the  fracture  involves  them  or  they  have  been 
subjected  to  traumatism,  is  imperative. 

The  reduction  of  greenstick  fractures  requires,  as  already 
stated,  the  exercise  of  more  or  less  force.  This  should  be 
applied  in  such  a  manner  as  immediately  and  completely  to 
overcome  the  angularity;  for,  although  the  fracture  may  be 
thus  made  complete,  the  result  is  definite  and  accomplished, 
and  is  therefore  much  more  satisfactory  than  any  effort  to 
restore  the  bone  to  proper  line  by  gradual  pressure.  This 
is  also  true  of  certain  impacted  fractures,  and  of  fractures 
which  have  become  partially  united  in  a  faulty  position. 
Should  union  of  the  latter  have  become  so  firm  as  to  resist 
manual  force,  the  osteoclast  may  at  times  be  advantageously 
employed  to  accomplish  the  result.  After  reduction  the  frag- 
ments seldom  show  much  tendency  to  become  again  dis- 
placed, and  their  fixation  is  obtained  and  their  subsequent 
management  proceeded  with  by  the  method  appropriate  for 
the  fracture. 


CHAPTER    II. 
FRACTURES   OF   THE    UPPER    EXTREMITY. 

FRACTURES    OF    THE    HAND. 

Phalanges. — The  phalanges  are  usually  fractured  either 
by  force  directed  against  the  tips  of  the  fingers  or  knuckles, 
as  in  a  faulty  attempt  to  catch  a  ball  or  in  striking  a  blow 
with  the  fist,  or  by  being  crushed  between  two  hard  objects, 
such  as  parts  of  a  machine  or  a  heavy  stone  and  the  ground. 
The  former  less  severe  violence  is  illustrated  in  Fig.  9;  the 
latter,  a  severe  crushing  force,  in  Fig.  10.  The  deformity 
occurring  after  fracture  of  the  phalanx,  depending  princi- 
pally upon  the  inclination  of  the  plane  of  fracture,  is 
slight  if  this  plane  is  transverse ;  greater  if  it  is  oblique 
(Figs.  9,  10).     The  fracture  may  involve  a  joint. 

Diagnosis. — Pain  and  swelling,  indicating  the  possible 
presence  of  fracture  of  one  of  the  fingers,  abnormal  mobility 
and  crepitus,  may,  in  some  instances,  be  readily  elicited  by 
palpation.  A  fracture  is  distinguished  from  a  luxation  of  a 
phalangeal  or  metacarpo-phalangeal  joint  by  a  much  more 
noticeable  deformity  of  the  latter,  and  by  the  ease  with  which 
the  deformity  may  be  overcome  in  fracture.  If  the  whole 
hand  has  been  injured,  careful  examination  of  each  finger  in 
turn  becomes  necessary  in  order  to  recognize  the  full  extent 
of  the  injury. 

Treatment. — As  the  force  required  to  fracture  a  phalanx 

25 


26  A    CLINICAL    TREATISE    OX  FRACTURES. 

is  great,  the  pain  following  such  an  injury  requires  relief. 
A  lotion  of  lead-water  and  laudanum  may  therefore  be  used 
during  the  first  day  or  two.  A  splint  made  of  a  cigar-box  or 
a  piece  of  wood  of  like  thickness  is  shaved  with  a  penknife 

Fig.  q. 


m  1 


Skiagraph  of  fracture  of  the  fourth  proximal  phalanx. 

into  a  shape  approximately  that  of  the  flat  hand.  If  the  sur- 
geon prefers  not  to  depend  upon  his  eye  in  modelling  such 
a  splint,  its  outline  can  be  easily  traced  around  the  sound 
hand,  the  hand  surface  of  the  splint  then  being  reversed,  of 
course,  for  the  opposite  side.  A  mass  of  oakum,  sufficient 
when  compressed  to  fill  out  the  hollow  of  the  hand,  is 
retained   with   a   bandage.      Upon    this    a   single   layer   of 


FRACTURES    OF   THE    UPPER   EXTREMITY.  2J 

canton-flannel  or  patent  lint  is  laid,  and  the  hand  is  allowed 
to  rest  upon  it.  A  little  cotton  is  inserted  between  each 
finger,  in  order  to  prevent  the  contact  of  opposing  skin 
surfaces,     which,     particularly    about    the    fingers,    become 

Fig.  io. 


Skiagraph  of  multiple  fractures  from  crush  of  hand. 

extremely  foul  from  retained  perspiration.  In  many  in- 
stances the  finger  that  is  broken  requires  no  special  atten- 
tion. It  is  well  supported  between  the  fingers  adjoining,  the 
splint  beneath,  and  the  retaining  bandage  above.  This 
latter  should  be  two  inches  wide,  and  is  most  neatly  applied 


28  A    CLINICAL    TREATISE    ON  FRACTURES. 

in  the  form  of  a  spica  of  the  hand.  Should  any  particular 
tendency  be  found  to  displacement  in  some  one  direction,  it 
may  be  prevented  by  a  compress  of  muslin  above  at  a  suit- 
able point.  This  compress  may  be  prevented  from  slipping 
out  of  position  by  a  half-inch  rubber  adhesive  strip,  carried 
from  the  under  surface  of  the  splint  around  and  over  the 
compress  and  back  to  the  under  surface  of  the  splint.  If  the 
dressing  is  found  after  the  first  application  to  have  become 
displaced  from  any  cause,  the  narrow  strip  of  rubber  adhe- 
sive plaster  may  be  applied  in  a  figure-of-eight  turn,  includ- 
ing tips'  of  fingers  and  wrist  in  order  to  give  increased  sup- 
port to  the  bandage.  In  some  cases  in  which  it  is  prudent 
to  give  greater  liberty  to  the  patient  than  is  possible  when 
the  entire  hand  is  confined,  very  neat  splints,  somewhat 
pear-shaped,  corresponding  in  form  to  the  palm  of  the  hand 
and  the  injured  finger  and  the  finger  next  to  it,  retained  in 
the  manner  just  described,  will  be  found  to  give  sufficient 
support  and  fixation  to  the  broken  fragments.  Such 
splints  are  very  useful  in  fractures  of  the  distal  phalanges, 
particularly  of  the  ring  and  little  fingers;  cardboard,  the 
thickness  of  cigar-box  wood,  is  also  a  convenient  material 
of  which  to  construct  these  splints. 

Metacarpal  Bones. — Fracture  of  the  metacarpal  bones  is 
caused  by  direct  violence,  as  by  the  hand  being  caught  in 
machinery  or  beneath  a  falling  object.  The  fracture  thus 
produced  is  inclined  usually  to  be  transverse,  and  is  accom- 
panied by  the  minimum  degree  of  deformity  (Figs,  n  and 
12).  When  caused  by  indirect  violence,  as  by  a  blow  of 
the  fist  or  a  fall  upon  the  knuckles,  the  overlapping  of  the 


FRACTURES   OF  THE    LFPER   EXTREMITY. 


29 


fragments  produces  sufficient  deformity  to  be  at  times 
plainly  noticeable.  The  bowing  usually  observed  is  dorsal, 
but  occasionally  palmar.  Fig.  13  represents  a  remarkable 
fracture  of  three  metacarpal  bones  in  line. 


fig.  11. 


Skiagraph  of  fracture  of  fourth  and  fifth  metacarpals. 

Diagnosis. — The  hand  becomes  swollen  very  soon  after 
the  receipt  of  such  an  injury,  considerable  tension  of  the 
integument  upon  its  dorsum,  with  perhaps  effusion  of  blood 
in  mass  into  the  subcutaneous  cellular  tissue,  occurring 
immediately.  In  all  cases,  therefore,  presenting  these 
appearances  very  careful  examination   should   be  made  of 


3° 


A    CLIXICAL    TREATISE    OX  FRACTURES. 


each  metacarpal  bone  in  turn.  The  first  step  of  the  exami- 
nation consists  in  thrusting  the  finger  against  the  head  of 
its  metacarpal  bone.  The  object  of  this  manoeuvre  is  both 
to  reveal  any  yielding  that  may  exist   and  to  locate  pain. 

Fig.  12. 


Skiagraph  of  oblique  fracture  of  fourth  metacarpal. 

If  these  movements  cause  pain  in  the  hand,  a  fracture  will 
generally  be  discovered.  The  next  step  is  the  attempt  to 
sway  backward  and  forward  the  head  of  the  metacarpal 
bone  whilst  the  middle  of  the  shaft  is  grasped  between 
the  thumb  and  finger  of  the  other  hand,  making  an  attempt 
at  a  counter-movement.  Mobility  can  usually  be  detected 
in  this  way  without  using   force  sufficient  to  cause   much 


FRACTURES    OF   THE    UPPER   EXTREMITY. 


31 


pain.  The  final  step  in  the  examination,  if  a  fracture  has 
been  found,  consists  in  locating-  as  far  as  possible  its  posi- 
tion by  direct  palpation.  As  force,  either  directly  or  indi- 
rectly applied,  which  has  been  violent  enough  to  fracture 
a   metacarpal  bone,   may  very    likely   have   fractured    more 

Fig.  13. 


Skiagraph  of  fracture  of  the  three  metacarpal  bones. 

than  one,  the  exploration  should  be  persisted  in  until  each 
bone  has  been  thoroughly  examined. 

Prognosis. — In  most  hands  the  metacarpal  bones  are  so 
superficially  situated  beneath  the  dorsal  integument  that  a 
resulting  deformity  too  trifling  to  interfere  with  the  ulti- 
mate usefulness  of  the  hand  may  yet  be  plainly  noticeable 


32  A    CLINICAL    TREATISE    ON  FRACTURES. 

on  inspection.  In  cases,  therefore,  in  which  decided  dis- 
placement exists  immediately  after  the  injury,  it  is  unwise 
to  promise  too  perfect  a  result,  so  far  as  appearance  is  con- 
cerned. 

Treatment. — Whether  one  or  more  metacarpal  bones  are 
fractured,  the  careful  adaptation  of  a  palmar  splint  is  equally 
appropriate  for  the  management  of  the  injury.  Shaping  a 
thin  plank  either  by  the  eye  or  by  tracing  the  outline  of  the 
sound  hand  and  forearm  upon  it,  it  is  shaved  to  correspond 
nicely  with  the  latter,  and  a  mass  of  oakum,  which  when 
compressed  will  be  about  a  quarter  of  an  inch  in  thickness, 
and  a  ball  of  oakum  sufficient  comfortably  to  fill  out  the 
cavity  of  the  hand,  is  retained  with  the  bandage  ;  or,  if  more 
positive  pressure  upward  at  this  point  is  required,  combined 
with  flexion  of  the  fingers,  in  order  best  to  effect  adjustment, 
sufficient  eminence  may  be  obtained  by  the  use  of  a  roller 
bandage  placed  on  the  splint  and  covered  with  oakum.  The 
limb  being  placed  upon  this  splint,  a  little  cotton  is  inserted 
between  each  finger,  and,  modelling  the  hand  upon  it,  it  is 
made  to  fit  nicely.  Should  any  dorsal  bowing  be  found  to 
exist,  a  small  compress  of  muslin  should  be  retained  upon 
the  refractory  fragment  by  a  quarter-inch  strip  of  rubber 
adhesive  plaster  carried  around  splint  and  hand,  the  splint 
having  been  retained  with  a  neatly  applied  two-inch  roller 
bandage.  The  dressing  is  completed  by  the  adjustment  of  a 
handkerchief  sling,  which  supports  the  splint  from  end  to 
end.  This  dressing  should  be  inspected  after  twenty-four 
hours,  and,  if  the  limb  is  found  in  a  satisfactory  condition, 
the  dorsum  of  the  hand  and  forearm  may  be  bathed  with 


FRACTURES   OF   THE    UPPER  EXTREMITY.  33 

alcohol  and  a  new  bandage  applied  without  removing  the 
splint.  The  interval  between  the  succeeding  changes  of 
the  dressing  should  be  four  days,  passive  motion  being 
made  of  every  controlled  joint  from  the  third  dressing 
throughout  the  treatment.  The  splint  should  be  worn  five 
davs  after  the  fracture  appears  firm,  which  will  usually  be 
found  to  be  in  three  and  a  half  weeks. 

Carpal  Bones. — The  force  required  to  fracture  one  or 
more  of  the  bones  of  the  carpus  is  so  great  that  damage  to 
the  adjacent  soft  parts  almost  invariably  accompanies  the 
fracture.  Such  an  injury  usually  involves  a  crush  of  the 
hand,   or  at  least  a  compound  fracture. 

FRACTURES  OF  THE  FOREARM. 

Fractures  of  the  Radius. — The  radius  may  be  broken  by 
direct  violence,  as  from  a  blow,  or  by  indirect  violence — that 
is,  force  directed  from  below  upward,  from  above  down- 
ward, or  from  a  crushing  force  acting  between  the  elbow 
and  wrist  in  the  direction  of  the  long  axis.  As  with  other 
bones,  a  fracture  caused  by  direct  violence  is  likely  to  be 
transverse;  when  by  indirect  violence  the  tendency  is  gen- 
erally towards  obliquity.  For  convenience  of  description, 
fractures  of  the  radius  may  be  divided  into  (1)  fractures  of 
the  lower  extremity,  (2)  fractures  of  the  shaft,  and  (3) 
fractures  of  the  upper  extremity. 

(1)  Fractures  of  the  Lower  Extremity  of  the  Radius. — 
In  a  very  large  proportion  of  fractures  of  the  radius  the  lower 
extremity  of  the  bone  is  the  seat  of  fracture.  As  all  fract- 
ures in  this  vicinity,  whether  involving  the  joint  or  occur- 
3 


34  A    CLINICAL    TREATISE    ON  FRACTURES. 

ring  a  short  distance  above,  present  peculiar  characteristics, 
they  may  be  classified  under  the  heading  given  above.  Colles 
long  ago  described  this  fracture  as  occurring  at  about  one 
inch  and  a  half  above  the  joint,  and  for  all  clinical  purposes 
his  original  definition  may  well  stand.  No  other  fracture, 
certainly  of  the  upper  extremity,  has  been  for  nearly  a  cen- 
tury the  subject  of  so  much  discussion  and  such  a  vast 
amount  of  literature  as  this.  This  is  not  only  because  of 
its  great  frequency,  but  also  because  permanent  deformity, 
producing  an  unsightly  result  and  interfering  with  the 
functions    of    the    limb,    so    often    follows    its   occurrence. 

Fig.  14. 


Recent  fracture  of  lower  end  of  the  radius. 

The  deformity  (Fig.  14)  following  a  fracture  of  the  lower 
end  of  the  radius  consists  of  dorsal  displacement  of  the 
lower  fragment,  the  latter,  besides  occupying  a  position 
above  the  axis  of  the  shaft  of  the  bone,  being  usually  turned 
somewhat  inward,  causing  thereby  undue  prominence  of  the 
lower  end  of  the  ulna.  The  hand  is,  therefore,  elevated  to 
a  higher  plane  than  natural  and  is  more  or  less  abducted. 
The  result  of  this  displacement  is  the  characteristic  "silver 
fork"  deformity  of  hand  and  wrist.  The  position  assumed 
by  the  fragments  producing  this  deformity  is  shown  in 
Fig.  15.  If  the  deformity  persist,  the  strength  and  useful- 
ness of  the  hand  are  permanently  lessened,  for  the  flexor  and 


FRACTURES    OF   THE    UPPER   EXTREMITY.  35 

extensor  muscles,  instead  of  acting  on  a  straight  mortise  at 
the  wrist-joint,  act  on  a  mortise  the  plane  of  which  is  oblique. 
The  obliquity  of   the  plane  on  the  articular  surface  of  the 

Fig.  15. 


Skiagraph  of  fracture  of  lower  end  of  the  radius,  the  dim   shadow  of  the  soft  parts 

showing  the  deformity. 

radius  allows  force  directed  by  a  muscle  upon  the  hand  and 
fingers  to   be  to  a    considerable    extent   lost   by  the  sliding 

Fig,  16. 


Skiagraph  of  fractures  of  both  radii. 


movement  of  the  carpus.     This  is  well  shown  in  Fig.  16,  a 
skiagraph  of  fractures  of  both  radii. 

The  other  cause  of  impairment  of  function  is  rigidity  of 


2,6  A    CLINICAL    TREATISE    ON  FRACTURES. 

the  wrist  and  fingers.  The  fracture  is  caused  most  fre- 
quently by  falls  upon  the  palm  of  the  hand;  occasionally, 
upon  the  back  of  the  hand.  The  fracture  in  such  instances 
has  been  said  to  be  caused  by  forced  extension  and  forced 
flexion.  I  think,  however,  in  most  cases  direct  impact, 
communicated  through  the  carpus,  best  describes  the  mode 
in  which  the  injury  is  usually  produced.  This  opinion 
depends  upon  experiments  in  producing  fractures  on  the 
cadaver,    as  illustrated  in  Fig.    17,   in  which  the  blow  was 


Fig,  17, 


Experimental  fracture  of  the  radius ;  frozen  section  at  the  outer  side  of  the  middle 
finger.     (From  a  drawing  by  Dr.  J.  Madison  Taylor.) 

delivered  directly  upon  the  base  of  the  carpus;  and  upon 
the  conviction  that  the  hand  in  most  individuals  can  be 
extended  to  a  right  angle  with  the  forearm  without  causing 
a  ligamentous  strain  sufficient  to  produce  fracture.  When 
the  carpus  has  reached  the  limit  of  its  motion  in  either 
flexion  or  extension,  as  when  the  hand  is  caught  in 
machinery,  the  radius  may  yield  from  the  lever-like  force 
exerted  upon  its  lower  extremity  at  the  wrist.  Force  so  act- 
ing is  called  a  cross-breaking  strain.  While  force  applied 
in  such  a  way  may  at  times  operate  in  this  manner,   that 


FRACTURES   OF  THE    UPPER   EXTREMITY. 


37 


it  does  so  frequently  has  not  been  demonstrated.  Often 
the  internal  lateral  ligament  of  the  wrist-joint  is  itself 
torn,  or  else  it  is  detached  from  the  lower  end  of  the  ulna, 
carrying  with  it  a  portion  of  the  styloid  process  of  the 
latter.  Undue  prominence  of  the  lower  end  of  the  ulna 
results.     Recent  observations,   demonstrated  by  skiagraphy, 


Fig.  18. 


Fig.  19. 


Skiagraph  of  fracture  of  the  styloid  process  Skiagraph  of  fracture  of  the  lower  end 
of  the  radius,  including  the  dorsal  lip  of  of  the  radius,  just  above  the  articula- 
ble articular  surface.     Barton's  fracture.  tion. 

indicate  that  this  ulnar  prominence  accompanying  Colles's 
fracture  is  more  frequently  produced  by  detachment  of  the 
tip  of  the  styloid  process  than  was  formerly  believed.  The 
curious  error,  however,  has  occurred  of  mistaking  the  lower 
epiphysis  of  the  ulna  for  fracture. 

While,  as  stated,  the  fracture  is  most  commonly  situated 
from  three-quarters  of  an  inch  to  an  inch  and  a  quarter 
above  the  tip  of  the  styloid  process  of  the  radius,  the  latter 


38 


A    CLINICAL    TREATISE    ON  FRACTURES. 


Fig.  20. 


may  be  involved,  as  shown  in  Fig.  18,  constituting  the  fract- 
ure described  by  Barton  ;  or  the  line  of  fracture  may  extend 

just  above  the  articular  surface, 
as  in  Fig.  19  ;  or,  again,  as  in 
Fig.  20,   somewhat  higher. 

Diagnosis.  —  Pain,  swelling, 
loss  of  power,  and  deformity  of 
greater  or  less  degree,  as  shown 
in  Fig.  14,  indicate  the  probable 
existence  of  fracture,  before  the 
examination  has  proceeded  as  far 
as  palpation.  Prominence  of  the 
lower  end  of  the  radius  on  the 
dorsal  aspect  of  the  forearm  ac- 
companied by  a  depression  at  a 
corresponding  point  on  its  palmar 
aspect,  slight  turning  of  the  hand 
to  the  radial  side,  and  more  or  less  projection  of  the  ulna  are 
signs  sufficiently  indicative  of  the  existence  of  the  injury. 
Crepitus  frequently  cannot  be  obtained,  and  so  much  force  is 
usually  required  to  reveal  preternatural  mobility  that  it  is 
far  better  to  make  no  effort  to  elicit  this  latter  sign  until 
reduction  is  about  to  be  accomplished. 

Reduction. — The  importance  in  this  fracture  of  imme- 
diate reduction,  and  that  as  complete  as  possible,  cannot  be 
over-estimated.  If  the  patient  shows  himself  unable  to  bear 
pain  well,  if  the  fracture  has  remained  unreduced  for  twelve 
or  twenty-four  hours,  or  if  an  effort  at  reduction  has  failed, 
it  is  entirely  proper  in  most  instances  to  use  an  anaesthetic. 


Skiagraph  of  fracture  of  the  lower 
end  of  the  radius,  just  above  the 
articulation. 


FRACTURES    OF   THE    UPPER   EXTREMITY.  39 

If  reduction  is  not  complete,  a  slight  displacement,  almost 
inappreciable  at  first,  will,  as  the  swelling  subsides,  steadily 
make  itself  more  and  more  apparent  at  each  inspection,  until, 
finally,  when  the  soft  parts  have  resumed  their  natural  con- 
tour, an  ugly  deformity,  too  firm  to  correct,  will  remain. 
While  sometimes  easily  reduced  under  the  proper  manipu- 
lation, many  cases  require  considerable  force.  Every  fract- 
ure should,  therefore,  be  approached  as  if  it  were  known  to 
be  refractory.  Seizing  with  the  right  hand  the  lower  third 
of  the  forearm,  with  the  fingers  placed  upon  its  palmar 
aspect,  the  thumb  rests  upon  the  dorsal  surface  of  the  lower 
fragment  ;  with  the  left  hand  the  hand  is  grasped,  the  fingers 
upon  its  dorsum,  while  the  thumb  rests  upon  the  palmar 
surface  of  the  upper  fragment.  The  right  thumb  presses 
directly  upon  the  lower  fragment,  with  counter-pressure  of 
the  fingers  upon  the  upper  fragment  ;  with  the  left  hand 
direct  pressure  is  made  upon  the  upper  fragment  with  the 
thumb,  while  counter-pressure  is  made  upon  the  hand  and 
wrist  with  the  fingers.  In  my  hands  this  manipulation  has 
never  failed,  in  a  recent  fracture,  to  accomplish  immediate 
reduction. 

Treatment.— Much  fault  may  be  found  with  the  Bond 
splint  unless  it  is  carefully  and  intelligently  applied  ; 
but  perhaps  no  dressing  for  fracture  of  the  lower  end  of 
the  radius  could  escape  criticism,  unless  used  with  great 
care  and  attention  to  necessary  details.  A  Bond  splint 
(Fig.  21)  applied  with  a  tight  bandage,  the  forearm  resting 
upon  scanty  padding  and  the  hand  elevated  high  upon  a 
wooden  block,  will  give  all  the  conditions  needed  to  retain 


40  A    CLINICAL    TREATISE    ON  FRACTURES. 

the  characteristic  deformity  of  the  fracture,  or  even  repro- 
duce it  if  it  has  been  overcome  ;  and  yet  I  have  never  seen 
FlG  2I  any  dressing  for   this    fracture 

which  better  fulfils  the  neces- 
sary requirements  if  it  is  prop- 
erly   employed.       Its    length 
Bonds  splint.  should   correspond    to  the   dis- 

tance from  the  inner  condyle  of  the  humerus  to  the  meta- 
carpophalangeal joints  of  the  hand,  while  its  breadth 
should  be  equal  to  or  slightly  greater  than  that  of  the 
forearm,  wrist,  and  hand  at  these  respective  points.  In 
order  to  preserve  the  natural  arch  of  the  radius  and  ulna, 
a  large  mass  of  oakum  should  be  placed  upon  the  splint, 
and  if  the  injured  limb  approximates  at  all  the  size  of  the 
surgeon's,  he  should  place  his  corresponding  forearm  upon 
it  and  pack  the  oakum  uniformly  beneath  it.  Placing  a 
single  layer  of  patent  lint  or  canton-flannel  upon  the 
oakum  is  all  that  is  necessary  to  complete  the  preparation 
of  the  splint. 

One  detail  relating  to  the  application  of  the  retaining 
bandage — that  is,  the  propriety  of  confining  the  fingers  so 
that  that  they  shall  be  beyond  the  control  of  the  patient 
— is  worthy  of  consideration.  Little  has  been  said  on  this 
matter  in  treatises  on  the  subject,  the  recommendation  by 
the  surgeon  of  the  splint  or  dressing  employed  by  him, 
as  one  which  retains  or  releases  the  fingers,  implying,  as 
a  rule,  his  tacit  approval  of  the  one  plan  of  treatment 
or  the  other.  A  few  surgeons  advise  the  use  of  a  splint 
which    reaches    to    the    tips    of    the    fingers  ;    but   perhaps 


FRACTURES    OF   THE    UPPER   EXTREMITY.  4 1 

a    greater  number  of  fractures  in    this   locality   are  treated 

o 

by  splints  which  extend  no  lower  than  the  metacarpo- 
phalangeal articulations  ;  and  such  splints,  used  as  they 
commonly  are,  permit  of  voluntary  motion  of  the  fingers 
and  thumb.  That  the  patient  frequently  avails  himself  of 
the  liberty  thus  given  him,  not  only  to  assist  his  sound 
hand  in  performing  numerous  acts  about  his  person  and 
at  his  work,  and  in  showing  his  friends  that  he  can  use 
the  fingers,  but  also  in  carrying  out  the  prevalent  belief 
that  the  more  he  does  so,  the  more  limber  will  they  be, 
is  abundantly  shown  by  the  quantity  of  foreign  matter, 
as  crumbs  of  bread,  tobacco,  sawdust,  and  dirt,  frequently 
found  to  have  accumulated  in  the  lower  portion  of  the 
dressing,  and  by  the  evident  dissatisfaction  which  control- 
ling his  fingers,  at  any  dressing  after  the  first,  causes  him. 
The  flexor  and  extensor  tendons  of  the  fingers  as  they 
pass  down  the  forearm  and  beneath  the  annular  ligament  are 
in  close  proximity  to  the  radius.  Any  alteration  in  the  con- 
tour of  the  bony  bed  upon  which  they  rest  encroaches  upon 
the  space  allotted  to  them.  When  a  fracture  occurs  in  this 
vicinity  more  or  less  damage  to  the  adjacent  soft  parts 
results.  The  tendons  and  their  sheaths,  the  nerves,  blood- 
vessels, and  connective  tissue  are  all  liable  to  injury,  any 
extent  of  bruising,  stretching,  or  tearing  being  possible  even 
in  a  simple  fracture.  The  tendons  and  their  sheaths  suffer 
most,  as,  especially  the  deep  flexors,  they  are  bound  down  so 
snugly  to  the  bone.  If  the  deformity  resulting  from  the 
fracture  be  at  once  and  entirely  overcome,  whatever  mischief 
was  done  by  the  fracture  or  by  the  force  producing  it,  to  the 


42  A    CLINICAL    TREATISE    OX  FRACTURES. 

neighboring  soft  parts,  remains  ;  but  no  new  irritant  is 
applied.  If,  on  the  contrary,  the  fragments  of  bone  have  not 
been  replaced  in  accurate  apposition,  a  persistent  source  of 
irritation  results  which  is  in  direct  proportion  to  the  extent 
of  the  deformity  remaining  and  to  the  sharpness  of  the  pro- 
jecting fragments  of  bone.  These,  then,  are  two  factors 
productive  of  inflammation.  Is  not  a  third  added  if  we 
permit  the  patient  to  use  his  fingers  ?  Voluntary  motion  of 
a  joint  involves  tension  of  the  tendons  which  impart  the 
motion.  Passive  motion,  on  the  other  hand,  may  be  prac- 
tised without  putting  the  tendons  materially  upon  the  stretch. 
There  can  be  no  doubt  that  the  principal  cause  of  impaired 
movement  of  the  fingers  and  wrist  after  this  fracture  is  to  be 
found  in  the  organized  inflammatory  exudates  along  the 
course  of  the  tendons  and  their  sheaths.  That  this  is  true 
becomes  apparent  when  attempts  at  passive  motion  are  made, 
during  which,  if  at  an  early  stage,  young  adhesions  along 
the  course  of  the  tendons  will  be  frequently  felt,  with  a 
distinct  impression  of  crackling,  to  give  way  and  release 
the  fingers,  while,  if  made  later  on,  the  rigidity  will  be 
found  to  be  of  a  springy,  yielding,  cadaveric  character, 
unlike  joint  ankylosis, — tendinous  rigidity.  Continued 
voluntary  action  of  these  tendons  about  the  wrist,  whose 
sheaths  have  been  more  or  less  damaged  and  perhaps  their 
calibre  lessened,  would  appear  to  promote  the  inflamma- 
tion already  started  and  to  increase  its  products.  The 
tendencv  of  muscular  contraction  to  reproduce  displace- 
ment, in  the  exceptional  cases  in  which  after  restoration  the 
fragments   are  inclined  to    become    displaced,   must  also  be 


FRACTURES   OF   THE    UPPER   EXTREMITY.  43 

borne  in  mind.     In  one  case  of  this  injury  which  came  under 
my  observation  the  lower  fragment  of  the  radius  was  reduced 
with  ease,  but  on  the  patient's  flexing  her  fingers  the  frag- 
ment  immediately   slipped  out   of    its    proper   position  and 
marked  deformity  was  reproduced.    After  a  second  reduction, 
the  patient,  although  warned  to  keep  her  fingers  still,  made 
another    movement    with    the    index    and    middle    finders, 
followed  by    a  like  result.     The    fragments    after  this  were 
supported  until  the  limb  was  placed  upon  a  splint.     To  over- 
come this  tendency  greater  pressure  of  the  retaining  dressing 
becomes  necessary.      It  is  therefore  desirable,  in  my  opinion, 
to  confine  the  fingers  bv  a  few  recurrent  turns  of  the  bandaee 
over  them  before  proceeding  to  retain  the  limb  to  the  splint. 
In  this  way  the  advantages  of  the  comfortably  flexed  position 
are  combined  with  perfect  rest.      In  order  to  prevent  contact 
of  the  skin  surfaces  a  little  cotton  should  be  placed  between 
the   fingers.      Passive   motion,    being    open    to   none  of   the 
objections  that  have  been    urged  against  voluntary  motion, 
should  be   begun  at  the   second  dressing  and  continued  at 
every    subsequent  change.      Each   finger  in   turn  should  be 
once  fully  flexed  and   fully   extended  ;  the   wrist   should   be 
once   flexed   and    extended,    once   pronated     and    supinated. 
These  movements    may   be    made   without  causing  pain  if 
they  are  done  gently  and  slowly.     The  forearm   should   in 
the  meantime  be  supported  by  the  fingers  and  thumb  of  the 
left  hand  placed  at  the  seat  of  fracture  ;  the  skin  is  bathed 
with  alcohol  at  each  dressing.     The  fingers  are  kept  at  rest 
by  the   recurrent    bandage    during    the    acute  inflammatory 
stage,     which    usually    subsides    at    the    end    of    ten    days. 


44  A    CLINICAL    TREATISE    OX  FRACTURES. 

After  the  second  dressing,  which  is  applied  twenty-four 
hours  after  the  first,  the  limb  should  be  dressed  every 
three  or  four  days  for  a  period  of  three  and  a  half  to  four 
weeks,  when  the  splint  may  usually  be  discarded.  For 
the  next  ten  days  various  light  exercises  for  the  fingers 
and  hand  should  be  encouraged,  and  their  activity  grad- 
ually increased  until  strength  is  fully  restored. 

(2)   Fractures  of   the  Shaft  of   the   Radius. — Fractures 
of  the  shaft  of  the  radius,  if  the  ulna  is  not  broken,  seldom 

Fig.  22. 


Skiagraph  of  fracture  of  the  lower  portion  of  the  shaft  of  the  radius. 

cause  great  deformity.  The  condition  is  well  illustrated 
in  Figs.  22  and  23.  The  forearm  is  very  slightly  shortened, 
and  what  displacement  of  fragments  exists  is,  so  far  as  its 
direction  is  concerned,  caused  more  by  the  inclination  of 
the  plane  of  fracture  than  by  the  contraction  of  any  muscles 
attached  to  the  bone  or  acting  upon  it.  The  biceps,  which 
has  always  been  considered  an  important  factor  in  causing 
forward  displacement  of  the  upper  fragment,  in  reality 
probablv  exerts,  when  the  forearm  is  flexed,  little  influence 
unless  the  fracture  has  occurred  just  below  the    tuberosity. 


FRACTURES   OF   THE    UPPER   EXTREMITY.  45 

The  action  of  the  quadratus  in  drawing  the  lower  frag- 
ment into  closer  proximity  with  the  ulna  has,  it  seems  to 
me,  been  very  much  overestimated. 

Diagnosis. — Pain,  swelling,  and  loss  of  power  are  gen- 
eral signs  indicating  the  existence  of  fracture.  Mobility 
at  some  point  between  the  elbow  and  wrist  can  readily  be 
revealed  by  gently  grasping  the  radial  aspect  of  the  forearm 
between    the    thumb    and    finger.     No    force  is  required  in 


Fig.  23. 


Skiagraph  of  fracture  of  the  shaft  of  the  radius. 

conducting  this  examination ;  the  tissues  do  not  require  to 
be  firmly  seized  in  order  to  elicit  motion,  and  the  patient 
need  be  caused  little  pain.  As  elsewhere,  the  seat  of  fract- 
ure having  been  once  distinctly  located  by  palpation,  any 
great  effort  to  elicit  crepitus  is  wholly  uncalled  for.  The 
fragments  may  be  so  placed  that,  instead  of  rubbing 
against  each  other  they  simply  sway  to  and  fro ;  and,  if 
there    be    no    overlapping   or   bowing   which    requires    cor- 


46  A    CLINICAL    TREATISE    OX  FRACTURES. 

rection,  the  immediate  management  of  the  case  can  be  pro- 
ceeded with. 

Treatment. — The  internal  right-angled  splint  (Fig.  24), 
extending  from  the  middle  of  the  arm  to  the  tips  of  the 
fingers,  of  a  width  corresponding  to  the  diameter  of  the 
arm,  should  be  prepared  by  retaining  with  a  bandage  upon 
its  surface  a  mass  of  oakum,  which  should  vary  in  thickness 
at  three  points :  (1)  From  the  upper  extremity  of  the  arm 
to  the  elbow  a  mass  of  oakum  should  be  placed  which 
when  compressed  will  make  a  comfortable  resting-place  for 
the  arm  and  elbow,  particularly  avoiding  pressure  upon 
the  internal  condyle  of  the  humerus.     (2)  In  order  further 

Fig.  24. 


Internal  right-angled  splint. 

to  protect  this  very  sensitive  point  from  pressure,  and  also 
to  preserve  the  natural  arch  of  the  forearm,  the  quantity  of 
padding  from  the  elbow  to  the  wrist  should  be  consider- 
ably increased  in  bulk.  (3)  At  the  palm  of  the  hand  the 
oakum  should  take  something  like  the  form  of  a  dome,  in 
order  to  adapt  itself  to  the  concavity.  To  get,  as  elsewhere, 
the  best  effect  of  the  elasticity  of  the  oakum,  it  should 
not  be  compressed  too  firmly  by  the  retaining  bandage. 
Upon  the  padded  splint  is  placed  a  single  layer  of  patent 
lint    or    canton-flannel,    cut    to    correspond    in    form    to    the 


FRACTURES   OF   THE    UPPER   EXTREMITY.  47 

right-angled  splint.  The  limb  is  then  placed  upon  the  splint, 
and,  carefully  inspecting  the  seat  of  fracture  and  making 
gentle  pressure  upon  it  with  the  hand,  about  equal  to  that 
which  will  presently  be  made  by  the  retaining  bandage,  any 
displacement  which  exists  should  be  overcome.  If  the  effect 
from  the  padding  is  found  insufficient,  as  evidenced  by  the 
radius  being  too  flat,  more  oakum  should  be  insinuated 
beneath  the  lint  covering.  If  the  internal  condyle  of  the 
humerus  seems  to  be  subjected  to  too  much  pressure  when 
the  elbow  is  pressed  upon,  a  small  ring  of  oakum  may  be 
inserted  beneath  the  lint  lining  to  protect  it.  In  order  to 
prevent  contact  of  the  skin  surfaces,  small  pledgets  of  cotton 
should  be  inserted  between  each  finger,  and,  if  the  forearm 
is  fleshy,  also  in  the  fold  at  the  bend  of  the  elbow.  While 
an  assistant,  or,  better,  two  assistants,  seize  the  upper 
extremity  of  the  splint,  holding  it  firmly  to  the  arm,  and 
the  lower  extremity  is  held  steadily  with  sufficient  support 
given  to  the  fingers  to  keep  the  hand  in  proper  place,  the 
retaining  bandage,  extending  from  the  tips  of  the  fingers  to 
the  upper  extremity  of  the  splint,  is  applied.  The  tension 
of  this  bandage  should  be  carefully  regulated  in  each  case. 
If  the  fracture  has  been  accompanied  by  severe  contusion 
of  the  soft  parts,  as  a  result  of  which  a  good  deal  of  swelling 
is  anticipated,  the  bandage  should  be  almost  slack  at  the 
first  dressing,  and  as  long  after  as  any  tendency  to  ascending 
inflammation  continues.  The  limb  should  never  be  allowed 
to  throb  nor  should  the  fingers  be  allowed  to  swell  out  of 
proportion  to  the  rest  of  the  limb.  A  broad  handkerchief- 
sling  is  then  nicely  adjusted  so  that   it  will   take  the  entire 


48  A    CLINICAL    TREATISE    ON  FRACTURES. 

weight  of  the  limb.  At  the  end  of  twenty-four  hours  the 
first  dressing  should  be  carefully  examined,  and,  if  the 
patient  complains  of  the  least  pain  at  any  point,  it  should 
be  removed.  The  presence  of  a  welt  of  padding,  corner 
of  splint,  or  a  turn  of  bandage  may  be  suspected  of  causing 
undue  pressure.  On  removing  the  bandage,  preferably 
with  scissors,  the  whole  dorsal  aspect  of  the  forearm  and 
hand  may  be  bathed  with  alcohol  without  in  the  least  dis- 
turbing the  limb.  If  the  splint  fits  well  and  the  condition 
of  the  skin  everywhere  is  satisfactory,  the  bandage  may  be 
reapplied  without  disturbing  the  limb  further.  This  dress- 
ing, if  entirely  comfortable,  and  if  the  retaining  bandage  is 
found  to  be  giving  sufficient  support  to  keep  the  fractured 
fragments  fixed,  may  be  allowed  to  remain  on  four  days, 
and  this  interval  between  dressings  may  be  continued 
throughout  the  treatment.  Union  usually  takes  place  at 
the  end  of  three  or  four  weeks ;  but  the  splint  should  be 
retained  for  one  week  longer. 

Retention  of  the  forearm  in  a  state  of  supination  for 
fracture  of  the  shaft  of  the  radius  above  its  middle,  in 
order  to  overcome  the  action  of  the  biceps  muscle  in  ele1 
vating  and  rotating  the  upper  fragment  outward,  is  unneces- 
sary ;  for,  in  my  experience,  no  muscle  in  the  body  relaxes 
more  completely  than  does  the  biceps  after  fracture.  Any 
power  it  exerts  upon  the  radius  is  voluntary,  never  spas- 
modic. Tenotomy  of  its  tendon,  therefore,  in  order  to  dis- 
able it,  must  seldom,  if  ever,  be  indicated.  Nor  is,  I  think, 
the  deforming  action  of  either  the  supinator  brevis  or  the 
pronator  radii  teres  important.     The  supine  position,   if  it 


FRACTURES    OF   THE    UPPER    EXTREMITY.  49 

is  not  required  to  effect  nice  apposition  of  the  fragments, 
is  not  advisable,  because  it  is  likely  to  be  so  uncomfortable 
to  the  patient;  nor  is  it  essential  to  the  greatest  inter- 
osseous separation. 

(3)  Fractures  of  the  Upper  Extremity  of  the  Radius. 
— Fractures  at  this  part  of  the  bone  are  less  frequent  than 
at  its  shaft,  and  are  very  rare  compared  with  those  at  its 
lower  extremity.  When  caused  by  direct  violence  they  not 
infrequently  form  a  part  of  some  general  injury  to  the 
elbow-joint.  When  produced  by  indirect  violence  the  latter 
is  likely  to  be  of  a  twisting  or  wrenching  character.  Fract- 
ure in  this  locality,  either  above  or  below  the  tubercle, 
seldom  causes  much  deformity.  When  the  forearm  is  in  a 
state  of  right-angled  flexion  tension  of  the  biceps  is  not  a 
factor  of  as  great  importance,  I  think,  as  has  been  ascribed 
to  it.  The  pain  and  disability  incident  to  fracture  will 
•always  be  found  to  cause  relaxation  of  the  biceps  and  con- 
sequent slackness  of  its  tendon,  certainly  within  a  very 
short  time.  The  traction  it  exerts  at  its  point  of  inser- 
tion, therefore,  is  usually  feeble.  If  the  fracture  be  in  the 
neck  of  the  bone,  the  biceps,  of  course,  tends  to  draw  the 
lower  fragment  forward  and  rotate  it  outward.  If,  on  the 
other  hand,  the  fracture  is  below  the  tubercle,  the  upper 
fragment  is  then  acted  upon  similarly  by  this  muscle. 
The  clinical  history  of  this  fracture,  however,  shows  that 
there  is  seldom  much  displacement,  and  what  displacement 
exists  can  hardly  be  determined  by  palpation.  Indeed,  the 
bare  detection  of  the  existence  of  fracture  is  not  easy,  and 

in    many    instances    requires    anaesthetization    to    verify    it; 
4 


50  A    CLINICAL    TREATISE    ON  FRACTURES. 

while  very  exact  localization  may  be  impossible  even  with 
the  aid  of  an  anaesthetic.  Hence  the  Roentgen  apparatus 
ma}',  in  a  suspected  fracture  in  this  locality,  be  of  great  use. 
Diagnosis. — Swelling  and  pain  on  motion  of  the  elbow- 
joint,  accompanied  by  marked  tenderness  on  pressure  at  one 
spot  over  the  upper  portion  of  the  radius,  suggest  the  prob- 
ability of  the  existence  of  fracture  at  that  point.  Seizing 
the  elbow  with  the  left  hand,  the  thumb  searches  for  the 
head  of  the  radius  in  its  proper  place  in  front  of  the  ex- 
ternal condyle  of  the  humerus.  In  some  subjects  it  can 
readily  be  detected,  while  in  others  it  is  masked  to  a  greater 
or  less  extent  by  fat  or  recent  cellular  infiltration.  When 
found,  the  thumb  is  kept  upon  it,  while  with  the  other  hand 
the  forearm  is  completely  pronated  and  supinated.  If  the 
head  of  the  radius  is  felt  to  rotate,  the  continuity  of  the 
bone  is,  of  course,  proved  to  be  intact,  either  because  there 
is  no  fracture  or,  there  being  a  fracture,  there  is,  owing  to 
impaction,  no  mobility.  While  conducting  the  movements 
of  pronation  and  supination  crepitus  may  be  communicated 
through  the  forearm  to  the  surgeon's  hand,  or  it  may  be 
felt  approximately  located  beneath  the  thumb  which  is 
held  over  the  supposed  seat  of  fracture.  While  this  is  the 
prescribed  method  of  detecting  fracture,  I  think  too  much 
stress  should  not  be  laid  upon  it,  because  in  many  sub- 
jects the  head  of  the  radius  is  too  deeply  placed  to  be 
readily  mapped  out,  and  is  also  too  smooth  to  convey  the 
impression  of  being  rotated  upon  its  axis.  The  fracture 
may  often  be  recognized  by  seizing  the  shaft  of  the  bone 
a   little    above    its   middle    and    lifting    and   depressing   it 


FRACTURES    OF   THE    UPPER   EXTREMITY.  5 1 

forcibly  and  repeatedly  while  the  fingers  of  the  left  hand 
palpate  over  its  upper  portion.  Preternatural  mobility  and 
crepitus  may  in  this  way  often  be  elicited,  and  the  position 
of  the  fracture  approximately  located.  This  is,  however, 
a  manoeuvre  requiring  so  much  force  that  an  anaesthetic, 
if  practicable,  should  be  used. 

Treatment. — While  on  anatomical  grounds  more  con- 
strained and  less  comfortable  positions  for  the  limb  have 
been  employed,  the  state  of  right-angled  flexion  of  the  fore- 
arm, with  the  degree  of  pronation  obtained  when  the  plane 
of  the  hand  is  vertical,  probably  best  overcomes  any  ten- 
dency to  displacement  of  the  fragments  which  may  exist. 
An  internal  right-angled  splint,  therefore,  employed  in  all 
respects  as  described  for  the  management  of  fracture  of  the 
shaft  of  the  bone,  is  applicable. 

Fractures  of  the  Ulna. — Fracture  of  the  styloid 
process  of  the  ulna,  while  it  may  occur  alone,  more  fre- 
quently accompanies  fracture  of  the  lower  end  of  the  radius. 
When  it  alone  is  fractured  the  injury  is  usually  caused  by 
direct  violence,  though  at  times  it  may  be  ascribed  to  trac- 
tion exerted  through  strain  of  the  internal  lateral  ligament 
of  the  wrist-joint.  If  the  fracture  accompanies  a  fracture  of 
the  lower  end  of  the  radius,  its  existence  may  be  overlooked 
in  attending  to  the  major  injury.  The  treatment  of  the 
latter,  however,  is  not  in  any  way  modified  by  its  presence. 

The  diagnosis  is  easily  made  by  palpation  if  attention 
is  drawn  to  the  injury.  If  not,  it  may  readily  escape  notice, 
as  little  or  no  deformity  results.  Localized  pain  and  tender- 
ness suggesting  the  possibility  of  such  a  fracture,  the  styloid 


52  A    CLINICAL    TREATISE    ON  FRACTURES. 

process  when  seized  beneath  the  thumb  and  finger  will  be 
found  movable,  and  crepitus  can  usually  be  elicited. 

Treatment. — As  there  is  only  a  slight  displacement  of 
the  fragments,  if  indeed  there  be  any,  to  retain  them  in 
a  state  of  fixation  a  properly  applied  palmar  splint,  so 
formed  that  it  will  retain  the  hand  in  a  state  of  moderate 
adduction,  fulfils  every  requirement.  This  splint  should  be 
prepared  by  shaving  it  into  a  somewhat  pistol-shaped  form, 
well  padded  with  oakum  retained  by  a  bandage.  It 
should  extend  from  the  tips  of  the  fingers  to  a  point  just 
below  the  internal  condyle  of  the  humerus.  When  covered 
by  a  layer  of  lint,  it  is  applied  to  the  forearm  by  a  bandage, 
the  pressure  of  the  latter  being  distributed  over  the  seat  of 
injury  by  the  intervention  of  a  layer  of  cotton.  The  dressing 
is  completed  by  the  application  of  a  broad  handkerchief- 
sling  extending  from  the  elbow  to  the  tips  of  the  fingers. 
The  splint  should  be  removed  at  the  end  of  twenty-four 
hours,  and  afterwards  at  intervals  of  five  days,  for  a  period 
of  two  and  a  half  weeks,  when  a  nicely  moulded  cardboard 
splint  will  usually  be  found  to  give  sufficient  support  for  the 
succeeding  ten  days  or  two  weeks  required  to  insure  union. 
As  there  is  seldom  any  difficulty  in  re-establishing  perfect 
restoration  of  function  after  this  fracture,  the  case  is  likely 
to  require  little  attention  when  the  splint  has  been  dis- 
carded. 

Fracture  of  the  shaft  of  the  ulna  is  most  frequently 
caused  by  direct  violence,  as  from  the  blow  of  a  heavy 
object,  the  bone  usually  yielding  directly  beneath  the  point 
of  impact.     The  plane  of  fracture  is  consequently  transverse, 


FRACTURES    OF   THE    UPPER   EXTREMITY. 


53 


and  the  tendency  to  relapse  is  relatively  slight.  Although 
the  deformity  in  a  very  large  number  of  cases  is  as  described, 
downward  bowing  or  dorsal  bowing,  the  brachialis  anticus, 
the  action  of  which  would  tend  to  cause  palmar  bowing, 
has  had  a  certain  importance  attached  to  it,  as  has  also  the 
pronator  quadratus,  in  tending  to  abduct  the  lower  fragment 
and  draw  it  toward  the  radius.  That  the  direction  of  the 
deformity  is  determined  by  either  of  these  muscles  may  well 
be  questioned,   for  not   only  does  interlocking  of  the  frag- 

Fig.  25. 


Skiagraph  of  fracture  in  lower  third  of  the  shaft  of  the  ulna.     Lower  fragment  perhaps 
acted  upon  by  the  quadratus. 

ments,  preventing  complete  loss  of  continuity,  interfere  with 
their  deforming  tendency,  but  the  action  of  the  former  is 
at  too  great  a  disadvantage  to  operate  forcibly,  and  the 
strength  of  the  latter  has  been  probably  overestimated, 
unless  the  fracture  be  situated  low  down  (Fig.  25).  Fig.  26 
illustrates  fracture  of  the  middle  of  the  shaft  of  the  ulna, 
and  Fig.  27  the  rare  condition  of  comminution  of  a  hacture 
at  this  point.  Figs.  28  and  29  show  fractures  at  the  upper 
third  of  the  bone. 


54 


A    CLINICAL    TREATISE    ON  FRACTURES. 


Diagnosis. — The  ulna  lies  so  superficially  beneath  the 
integument  that  its  whole  shaft  is  frequently  demonstrable 
to  palpation.  Mobility  may  be  elicited  by  lifting  and 
depressing  the  bone  with    the  thumb  and  finger  while  the 

Fig.  26. 


Skiagraph  of  fracture  of  the  middle  of  the  shaft  of  the  ulna. 

wrist  is  steadied  with    the  other  hand.       Crepitus   may  be 
felt,    but  often    cannot  be,    as  the   fragments  are  prevented 

Fig.  27. 


Skiagraph  of  comminuted  fracture  of  the  shaft  of  the  ulna. 

from  grating  together  by  being  more  or  less  interlocked. 
Green-stick  fracture  of  the  ulna  unaccompanied  by  radial 
lesion  is  rare,  as  the  force  causing  the  injury  is  much 
more  likely  to  act  with  approximate  equality  upon  both 
bones.     Fig.   30  well  illustrates  this  unusual  condition. 


FRACTURES    OF   THE    UPPER   EXTREMITY. 


55 


%\ 


Treatment. — An   internal   right-angled   splint,  applied 
as  has   been  described   above  in  the  management  of  fract- 
ures of  the  shaft  of  the  radius,  is  a  simple  and 
effective   plan    of   treatment   for   fracture    of  the 
shaft  of  the  ulna. 

Fracture  of  the  Olecranon   Process  of  the 
Ulna  (Fig.  31). — Though  this  process       fig'. 29. 
may  be  fractured  by  muscular  violence 
through  the  action  of  the  triceps  alone, 
it  is  much  more  frequently  broken  by 
direct    force,    as    by    a    fall    upon    the 
elbow,   to  which   is  added,   I  suspect, 
in  some  cases  the  element  of  muscular 
I       action.      The  upper  fragment  may  be 
very  small,  consisting  only  of  the  ex- 
HMf      treme  eminence  of  the   process,   or  it 
may  include  half  or  more  of  the  artic- 
ulating fossa.     The  smaller  the  frag-       the   shaft 
ment    which    has   been    detached,   the 

high  up. 

more  likely  is  muscular  violence  to 
have  been  the  chief  factor  in  the  causation  of  the  injury. 
The  upper  fragment  may  be  drawn  far  up  the  arm  by  the 
action  of  the  muscle,  but  more  frequently  it  is  little  sepa- 
rated from  the  shaft.  Some  remaining  continuity  of  fibres 
of  the  deep  fascia,  which  continues  down  the  forearm  in  a 
fan-like  extension  of  the  tendon  of  the  triceps  over  this 
part  of  the  bone,  accounts  for  the  slight  separation  of  the 
fragments  in  many  cases. 

Diagnosis.— As  does  the  shaft,   the   upper  extremity  of 


Fracture  of 
the  shaft  of 
the  ulna  at 
its  upper 
third. 


56 


A    CLINICAL    TREATISE    ON  FRACTURES. 


the  ulna  lies  so  superficially  beneath    the  integument  that 
loss   of  its  continuity,   especially  if  the  separation   be  con- 


Fig.  30. 


Skiagraph  of  green-stick  fracture  of  the  ulna,  unaccompanied  by  fracture  of  the  radius. 

siderable,   can    easily  be  detected.       Preternatural    mobility 

of  the  upper  fragment,  and  perhaps  crepitus,   can  best  be 

Fig.  31. 


Skiagraph  of  fracture  of  the  olecranon  process  of  the  ulna. 

elicited  by  palpation  when  the  forearm  hangs  relaxed  in  a 
state  of  complete  extension. 

Treatment. — In  the  majority  of  cases  separation  of  the 


FRACTURES    OF   THE    UPPER   EXTREMITY.  57 

fragments  is  too  slight  to  require  any  special  local  appliance 
to  correct  the  upward  displacement  of  the  upper  fragment. 
While  extreme  extension  of  the  forearm  anatomically  meets 
the  requirements  for  the  best  coaptation  of  fragments, 
extreme  extension  is  a  very  trying  position  for  the  patient, 
whether  he  is  on  his  back  or  is  up  and  about.  A  splint, 
therefore,  which  will  retain  the  forearm  in  a  state  of  only 
moderate  extension,  a  very  obtuse-angled  splint,  applied 
anteriorly,  in  the  great  majority  of  cases  effects  satisfactory 
coaptation  without  the  aid  of  such  adjuncts  as  compresses  or 
adhesive  plaster.  These  applied  in  a  perfunctory  manner  may 
do  more  harm  by  provoking  exudation  and  infiltration  about 
the  joint  than  good  by  promoting  coaptation.  They  are 
seldom  needed.  Approximation  of  the  fragments  by  suture 
in  rare  instances  may  be  justifiable,  but  should  never  be 
resorted  to  in  unhealthy  or  aged  subjects,  nor  under  surgical 
conditions  which  can  be  regarded  as  imperfect  in  any  partic- 
ular. An  obtuse-angled  splint,  or  a  long,  straight  splint, 
so  padded  that  it  will  allow  of  slight  flexion  at  the  elbow- 
joint,  extending  from  the  metacarpophalangeal  articulations 
to  the  head  of  the  humerus,  is  retained  to  the  arm  by  a 
bandage.  The  turns  of  the  latter  should  not  be  made  too 
tense  over  the  hand  and  forearm  lest  they,  combined  with 
the  dependent  posture  necessarily  assumed  by  the  limb, 
should  cause  uncomfortable  throbbing  or  swelling.  No  sling 
is  used.  Passive  movement  of  every  joint,  except  flexion  of 
the  elbow,  should  be  practised  at  each  dressing.  The  matter 
of  passive  motion  of  the  elbow-joint  is  one  of  the  greatest 
importance.     If  the    fragments   are   only  slightly    separated 


58  A    CLINICAL    TREATISE    ON  FRACTURES. 

and  appear  to  be  held  in  situ  by  tendinous  fibres,  passive 
flexion  of  the  elbow-joint  may  safely  be  made  as  soon  as 
complete  voluntary  control  can  be  got  of  the  triceps  muscle. 
This  may  usually  be  obtained  in  one  or  two  sittings,  but  in 
some  individuals  such  control  is  extremely  difficult  to  teach. 
In  the  uncommon  cases  in  which  separation  of  the  frag- 
ments to  a  considerable  extent  requires  long  retention  of  the 
splint  combined  with  some  controlling  device,  the  time  at 
which  passive  motion  should  be  begun  may  be  very  hard 
to  decide.  Confronted  by  the  alternative,  however,  of  a  rigid 
elbow-joint  or  the  risk  of  disturbing  newly  formed  callus, 
the  conditions  obtaining  in  any  individual  case  must  deter- 
mine the  time  most  appropriate  for  the  commencement  of 
passive  motion  and  the  extent  to  which  it  may  be  conducted. 

Fracture  of  the  Coronoid  Process  of  the  Ulna. — The 
coronoid  process  may  be  detached  by  any  force  which  will 
cause  a  backward  luxation  of  the  elbow-joint.  This  luxation 
it  often  accompanies,  though  that  the  latter  can  happen  only 
after  fracture  of  the  process,  is  disproved  clinically.  The 
natural  displacement  after  fracture  of  the  coronoid  process  is 
backward  luxation  at  the  elbow-joint,  for  it  furnishes  the  most 
definite  bony  support  the  joint  has  anteriorly,  that  given  by 
the  head  of  the  radius  being  variable  and  uncertain. 

Diagnosis. — The  presence  of  this  fractnre  is  usually  dif- 
ficult to  detect.  The  process  in  health  can  seldom  be  demon- 
strated by  palpation,  and,  as  it  is  usually  but  slightly  sepa- 
rated, crepitus  does  not  exist,  nor  can  the  detached  fragment 
be  felt.  All  cases  of  backward  dislocation  which  after 
reduction    immediately    relapse,    or   after   reduction    can    be 


FRACTURES    OF   THE    UPPER   EXTREMITY.  59 

thrown  out  again  and  once  more  reduced  by  slight  back- 
ward and  forward  efforts,  may  generally  be  assumed  to  have 
fracture  of  the  coronoid  process  accompanying  them.  This, 
for  reasons  which  will  appear  in  speaking  of  treatment,  is 
a  prudent  and  useful  assumption,  even  if  no  more  positive 
signs  of  fracture  can  be  discovered. 

Treatment. — Flexion  of  the  forearm,  as  completely  as  is 
consistent  with  the  patient's  comfort,  approximates  the  lower 
fragment  (shaft  of  the  ulna)  to  the  upper.  The  application 
of  a  Velpeau  bandage,  therefore,  without  the  use  of  any  splint, 
is  the  only  dressing  necessary.  As  this  treatment  is  applicable 
also  for  a  backward  dislocation  of  the  forearm,  it  obviously 
becomes  necessary  only  to  vary  the  length  of  time  for  the 
management  of  the  one  injury  or  for  the  two  combined.  A 
backward  dislocation  of  the  elbow  which  after  reduction  can- 
not be  reproduced  by  any  ordinary  effort  may  be  considered 
cured  in  ten  davs  and  released.  A  backward  dislocation 
of  the  elbow-joint  which  either  will  not  remain  reduced  or 
recurs  on  small  provocation  evidently  has  had  accompanying 
it  either  a  fracture  of  the  coronoid  process  of  the  ulna  or 
such  extensive  laceration  of  ligaments  anterior  to  the  joint 
that  the  course  of  treatment  necessary  to  restore  the  one  is 
as  long  as  that  required  for  the  other.  The  Velpeau  dress- 
ing, after  adjusting  a  single  layer  of  lint  at  every  joint  where 
skin  surfaces  will  be  in  contact,  is  applied  in  the  following 
manner  :  placing  the  hand  of  the  injured  extremity  on  the 
opposite  shoulder,  a  two  and  a  half-inch  muslin  bandage, 
starting  over  the  spine  of  the  scapula  on  the  sound  side,  is 
carried  across   the  back  to  the  injured  side  by  the  following 


60  A    CLINICAL    TREATISE    OX  FRACTURES. 

course  :  the  middle  of  the  summit  of  the  shoulder,  the 
middle  of  the  outer  aspect  of  the  arm,  behind  the  elbow, 
across  to  the  axilla  on  the  sound  side,  and  under  it  to  the 
starting-point.  Repeat  this  turn  to  fix  the  bandage.  On 
reaching  the  scapula  the  second  time,  make  a  circular  turn 
around  the  thorax,  including  in  it  the  arm  on  the  injured 
side.  The  external  condyle  of  the  humerus  is  the  point 
over  which  the  middle  of  the  roller  passes  on  its  way  back 
to  the  starting-point.  A  shoulder-turn  is  now  made,  which 
overlaps  the  fixing  turn  three-quarters  toward  the  median 
line  of  the  body  ;  then  another  ascending  spiral  turn  over- 
lapping the  preceding  turn  one-half.  So,  shoulder-turns  and 
spiral  turns  alternate  until  the  former  support  the  point  of 
the  elbow,  which  should  be  protected  by  a  lint  pad  having 
a  small  hole  in  its  centre.  After  this,  spiral  turns  alone  are 
continued  until  the  entire  injured  extremity  up  to  the  wrist 
is  thoroughly  supported.  Xo  sling  is  used  in  this  dressing. 
Pins  or  adhesive  plaster  must  be  generously  used  at  all 
intersections  of  turns. 

The  dressing  should  be  removed  on  the  third  day,  and 
reapplied  after  the  skin  has  been  thoroughly  cleansed  with 
alcohol.  Subsequent  dressings  should  be  removed  every 
three  or  five  davs.  Passive  movement  of  the  elbow-joint 
sufficient  to  extend  the  forearm  to  a  right  angle  with  the 
arm  may  be  made  cautiously  at  the  end  of  two  weeks. 
Pronation  and  supination  of  the  hand  may  be  done  passively 
at  the  same  time.  After  three  and  a  half  or  four  weeks  the 
Velpeau  dressing  may  be  discarded  and  the  forearm  simply 
carried  in  a  sliny  for  ten  davs  longer,  when  efforts  to  restore 


FRACTURES   OF   THE    UPPER   EXTREMITY.  6 1 

complete  extension  must  be  persisted  in  if  any  tendency  to 
rigidity  remains. 

Fractures  of  the  Shafts  of  the  Radius  and  Ulna.— 

Fracture    of    both    bones   of  the    forearm    causes   an    injury 

of  far  greater  impor- 

&  Fig.  32. 

tance,  both  regarding  1 
its  management  and 
its  results,  than  does 
fracture  of  the  shaft 
of  either  bone  alone. 
It  is  well  represented 
in  Figs.  32-36  and  40, 

Showing    the    Seat    of     L^~g~ph  of  fracture  0f  both  bones  of  the  forearm. 

fracture    at    slightly 

different  points  in  the  two  bones.     They  seldom  give  way 
at  a  corresponding  point,  but  the  line  of  fracture  is  more 

uniform  in  both,  and 

the    fractures    them- 

I  selves  are  more  likely 
to  be  transverse,  if 
caused  by  direct  vio- 
lence, than  if  by 
force  communicated 
through  the  hand  or 
elbow  indirectly.    If 

Skiagraph  of  fracture  of  both  bones  of  the  forearm. 

0  the       fractures       are 

transverse,  the  deformity  most  frequently  consists  of  ulnar 
bowing  (Fig.  36)  or  dorsal  bowing,  the  former  depending 
principally   upon   the   sagging    downward  of  the    fragments 


62 


A    CLIXICAL    TREATISE    OX  FRACTURES. 


while  the  hand  is  supported  by  a  sling  or  by  the  sound 
hand.  Dorsal  bowing,  if  it  exists,  is  usually  caused  by  the 
preponderance  in  strength  of  the  flexors  over  the  extensors 

FIG.  34. 


Skiagraph  of  fracture  of  both  bones  of  the  forearm. 

of  the   forearm.      Bowing   in  either  direction  may  be  pro- 
duced   by    the    force    causing    the    fracture,     the    position 

Fig.  35. 


Skiagraph  of  fracture  of  both  bones  of  the  forearm. 

assumed  having  been  determined  by  the  direction  of  this 
force.  This  is  particularly  true  of  green-stick  fractures  of 
the  forearm,  presently  to  be  mentioned.     Bowing  towards  the 


FRACTURES    OF    THE    UPPER   EXTREMITY.  63 

ulnar  side  is  the  deformity  which  most  frequently  must  be 
combated  throughout  the  treatment.  Even  where  the  plane 
of  fracture  is  oblique  there  is  seldom  any  considerable  over- 
lapping of  the   fragments ;    for   the   action    of  the   muscles 

Fig.  36. 


Skiagraph  of  fracture  of  both  bones  of  the  forearm,  showing  ulnar  bowing. 

concerned  tends  more  to  produce  bowing  at  the  seat  of 
fracture  than  overlapping  of  the  fragments.  In  children  in- 
complete or  green-stick  fracture  of  the  radius  and  ulna  is  fre- 
quently observed.  Green-stick  fracture  may  be  characterized 
by  no  other  sign  than  deformity  ;  there  being  often  no  mo- 
bility nor  crepitus.  The 
condition  is  well  illustrated 
in  Figs.  37-39.  The  bow- 
ing, having  been  caused  in 
most  cases  bv  the  original 


Fig.  37. 


injury,  may  assume  any 
direction,  and  the  incom- 
pleteness  of  the    fracture 

may  manifest  itself  in  One         Green-stick  fracture  of  the  radius  and  ulna, 

with  avulsion  of  arm  in  belting. 

bone  or  in  both  bones,  the 

bone    not   so    affected    being-   either  sound  or  the   seat  of  a 


64 


A    CLIXICAL    TREATISE    OX  FRACTURES. 


complete  fracture.  A  remarkable  example  of  the  character 
of  the  deformity  being  determined  by  the  mode  of  action 
of  the  force  which  caused  the  injury  occurred  in  the  case 
of  a  boy,  twelve  years  of  age,  whose  hand  was  caught  in 
a  heavy  belting.  The  limb  was  carried  into  the  wheel  and 
Fig.  38. 


Fig.  40. 


Skiagraph  of  green-stick  fracture  of  both  bones  of  the 
forearm 

Fig.  39. 


Skiagraph  of  complete  fracture  of  the  radius  with  green- 
stick  fracture  of  the  ulna. 


Fracture  of  both  bones 
of  the  forearm. 


dragged  off  at  a  point  just  below  the  shoulder-joint  at  the 
moment  the  boy's  chest  struck  the  wheel.  The  curve 
given  to  the  forearm  corresponded  to  the  curve  of  the  wheel, 
between  the  surfaces  of  which  and  the  heavy  belting  the  arm 
was  caught.      The   avulsed  extremity  is  shown  in  Fig.  37. 


FRACTURES   OF   THE    UPPER   EXTREMITY.  65 

Diagnosis. — Fracture  of  the  shaft  of  both  radius  and 
ulna  may  often  be  distinguished  from  fracture  of  the  shaft 
of  one  bone  only,  upon  mere  inspection,  by  the  greater 
deformity  it  produces.  All  support  of  the  forearm  is  gone. 
It  is  markedly  bowed  in  some  direction,  usually  to  the 
ulnar  side.  Mobility  is  so  complete  that  the  patient  is 
likely  to  dread  any  change  in  posture  on  account  of  the 
pain  it  causes.  As,  therefore,  the  nature  of  the  injury  is 
often  patent,  any  rough  handling  to  elicit  crepitus  is  quite 
unnecessary;  and  it  only  remains  to  locate  the  seat  of 
fracture  in  each  bone  by  delicate  manipulations.  Allowing 
the  forearm  to  rest  upon  a  pillow,  the  pivotal  point  of 
motion  in  each  bone  can  be  accurately  determined  by  gentle 
swaying  motions  with  the  index  finger  and  thumb,  while 
the  wrist  is  supported  by  the  other  hand. 

Treatment. — If  the  fracture  in  both  bones  is  complete, 
it  is  not  necessary  to  make  efforts  at  reduction  until  the 
dressing  is  ready  to  be  applied.  The  indications  in  the 
treatment  of  this  injury,  after  reduction,  are  :  (1)  Absolute 
fixation.  In  order  to  obtain  this  perfect  rest,  the  elbow  as 
well  as  the  wrist-joint  must  be  immobilized.  (2)  The  reten- 
tion of  the  forearm  in  such  a  manner  that  not  only  shall  the 
coaptation  of  the  fragments  be  as  perfect  as  possible,  but  the 
natural  dorsal  arch  of  the  bones  of  the  forearm  shall  also 
be  retained  and  the  interosseous  space  preserved.  Forcible 
reduction  by  extension  and  counter-extension  applied  to 
the  forearm  to  correct  overlapping  is  seldom  needed,  the 
muscular  relaxation  which  usually  occurs  immediately  upon 
or  very  soon  after  the  receipt  of  the  injury  allowing  reduc- 


66  A    CLIXICAL    TREATISE    OX  FRACTURES. 

tion  of  the  displacement  to  be  made  without  difficulty. 
The  injunction  occasionally  given  to  force  the  radius  and 
ulna  apart  from  each  other  at  the  seat  of  fracture  by  press- 
ure with  the  fingers,  to  prevent  fusion  of  the  two  bones, 
is  unnecessary.  If  the  object  were  attained,  the  result  would 
be  only  temporary;  and,  moreover,  in  evidence  afforded  both 
clinically  and  by  skiagraphs  of  a  very  large  number  of  these 
fractures,  tendency  to  fusion  has  been  demonstrated  to  be 
a  displacement  by  no  means  the  most  important. 

"While  hesitating  to  criticise  adversely  prescribed  methods 
of  treatment,  I  must  deprecate  the  use  of  the  double  (dorsal 
and  palmar)  splints  in  the  management  of  this  injury.  The 
intention  of  the  double  splint  is  to  preserve  the  form  of 
the  interosseous  space  by  pressing  the  muscles  into  it  from 
above  and  below.  I  have  found  the  dorsal  splint  wholly 
unnecessarv  for  the  fulfilment  of  this  indication,  and  I  have 
rarelv  removed  it,  even  after  it  has  been  applied  by  experi- 
enced hands,  without  observing  an  incipient  splint-sore 
over  the  carpus.  Applying  pressure  as  these  two  splints 
do,  in  parallel  planes,  sufficient  support  is  not  given  to  the 
forearm  to  prevent  ulnar  sagging,  and  the  palmar  splint 
is  seldom  padded  sufficiently  to  preserve  the  natural  arch 
of  the  forearm.  Not  only  is  the  elbow-joint  uncontrolled, 
but  if  the  fracture  is  as  high  up,  in  either  or  both  bones, 
as  the  junction  of  the  middle  with  the  upper  third,  not 
even  are  the  upper  fragments  controlled.  That  this  is  true 
can  easilv  be  demonstrated  by  our  ability  to  recognize  the 
existence  and  approximately  the  locality  of  the  fracture, 
while   the   splints   are   still   in   place,  by  simply   seizing  the 


FRACTURES    OF   THE    UPPER   EXTREMITY.  6j 

splints  with  one  hand  and  the  elbow  with  the  other.  The 
seat  of  fracture  will  then  be  felt  to  be  imperfectly  controlled 
and  freely  movable.  Every  surgeon  who  has  had  the 
opportunity  of  seeing  many  fractures  of  these  bones  treated 
is  aware  that  delayed  union  and  ununited  fracture  in 
healthy  subjects  occur  relatively  with  greater  frequency  than 
elsewhere,  and  I  believe  that  one  important  cause  for  such 
untoward  results  may  be  found  in  imperfectly  controlled 
upper  fragments.  An  internal  right-angled  splint,  applied 
in  the  manner  described  on  page  46,  is,  in  my  opinion,  uni- 
versally applicable.  This  dressing,  if  entirely  comfortable, 
and  if  the  retaining  bandage  is  found  to  be  giving  sufficient 
support  to  keep  the  bones  fixed,  need  be  changed  only  once 
in  four  days.  At  each  change  passive  motion  of  the  wrist 
and  fingers  may  be  made.  The  splint  should  be  retained 
for  one  week  after  both  bones  are  found  to  be  firm,  which 
they  usually  are  in  from  three  and  a  half  to  four  and  a  half 
weeks.  The  splint  may  therefore  generally  be  discarded  in 
from  four  and  a  half  to  five  and  a  half  weeks. 

FRACTURES     OF    THE    HUMERUS. 

Fractures  of  the  humerus  may  be  described  under  three 
headings,  as  fractures  of  the  lower  end,  of  the  shaft,  and  of 
the  upper  end.  Fracture  of  the  lower  extremity  of  the 
humerus  is  especially  an  injury  of  childhood,  except  when 
produced  by  a  crushing  force,  as  between  the  buffers  of  cars. 
Fracture  of  the  shaft,  as  it  usually  presents  itself,  occurs  in 
adult  life,  while  fracture  of  the  upper  extremity  belongs  to 
advancing-  or  old  aee. 


68  A    CLINICAL    TREATISE    OX  FRACTURES. 

Fractures  of  the  I^ower  End  of  the  Humerus.— Fract- 
ure in  this  neighborhood  may  or  may  not  involve  various 
portions  of  the  articular  surfaces  of  the  bone.  The  line  of 
fracture  may  thus  extend  transversely  just  above  both  con- 
dyles, constituting  a  supracondyloid  fracture  (Figs.  41  and  42); 

Fig.  41. 


Skiagraph  of  supracondyloid  fracture  of  the  humerus. 

or  such  a  fracture  may  have  intersecting  it  a  vertical  fracture 
between    the    condyles,    producing   the   so-called  T-fracture. 
(See  Fig.  46.)     The  epitrochlea  of  the  external  condyle,  or 
the  epicondyle  within,  may  be  broken  off  without         FlG 
any  involvement  of  the  elbow-joint  ;  or,  finally, 
the  line  of  fracture  may  extend  from  between 
the  condyles  to  a  point  a  short  distance  up  the 
shaft.     If  such  a  fracture  emerges  at  the  outer 
side,   it  causes  a  fracture  of  the    external   con- 
dvle;  while  if  on  the  inner  side,  a  fracture  of  the 

Supracondyloid 

internal  condyle.      Fig.  43  represents  a  fracture       fracture  of  the 
of  the  external  condyle  which  involved  so  much 
of  the  articular  surface  of  the  bone  that  that  portion  remain- 
ing  intact   readily  slipped  by  the    coronoid    process  of  the 
ulna,  thus  permitting  a  backward  dislocation  of  the  forearm. 


FRACTURES    OF    THE    UPPER    EXTREMITY. 


69 


Fractures  of  the  lower  end  of  the  humerus  are  usually  pro- 
duced by  indirect  violence,  a  most  frequent  cause  being  falls 
upon  the  hand.     The  complex  character  of  the  ossification 


Fig.  43 


Skiagraph  of  fracture  of  the  external  condyle  of  the  humerus. 

of  this  portion  of  the  bone  beginning  in  early  childhood 
determines  the  various  lines  of  fracture  to  a  considerable 
extent  at  this  tender  age,  but  it  is  a  factor  which  steadily 

Fig.  44. 


Skiagraph  of  separation  of  the  lower  epiphysis  of  the  humerus,  accompanied  by  backward 
dislocation  of  the  forearm. 

diminishes  towards  adult  life.  Occurring  before  the  eigh- 
teenth year,  they  are  apt  to  be  epiphyseal  separations  rather 
than  fractures,  but  their  general  character  is  not  thereby 
altered.    Fig.  44  illustrates  such  a  separation  with  dislocation. 


yo  A    CLINICAL    TREATISE    ON  FRACTURES. 

Diagnosis. — As  fractures  about  the  elbow-joiut  cause 
rapid  swelling  and  are  extremely  painful  on  motion  and 
exquisitely  sensitive  to  pressure,  and,  finally,  as  upon 
their  accurate  recognition  and  consequently  their  proper 
management,  restoration  of  function  largely  depends,  the 
use  of  an  anaesthetic  is  to  be  strongly  advised.  Deformity, 
which,  if  it  exists,  furnishes  sufficient  evidence  of  fracture, 
may  be  of  little  aid  in  suggesting  the  particular  line  which 
the  fracture  has  followed.  It  is  a  symptom  to  which  too 
much  importance  should  not  be  attached.  In  many  fract- 
ures of  the  humerus  about  the  elbow-joint  the  deformity 
suggests  a  luxation  as  much  as  it  does  a  fracture,  and 
in  a  great  many  cases  there  is  no  deformity  observable 
(Fig.  45).     With  this  understanding,   it  may  be  stated  that 

Fig.  45. 


Skiagraph  of  supracondyloid  fracture  of  the  humerus,  unaccompanied  by  deformity. 

the  width  of  the  joint  is  increased  in  any  fracture  involv- 
ing the  articular  extremity  of  the  bone,  whether  of  the 
external  or  the  internal  condyle,  or  the  splitting  of  the 
bone  between  them,  the  line  of  fracture  terminating  either 
a  considerable  distance    up  on   the   shaft  or   in  a  supracon- 


FRACTURES   OF   THE    UPPER  EXTREMITY, 


71 


dyloid  fracture.      Fracture  of  the  internal  condyle  allows  the 

forearm  to  be  drawn  inward,  while  fracture  of  the  external 

condyle  causes  outward  displacement.     Having  gone  through 

the  manipulations  appropriate  for  the  detection        Fig.  46. 

of  fracture  of  the  neck  of  the  radius  and  of  the 

upper  end  of  the  ulna,  which  have    eliminated 

any  involvement  of  these  bones,  the  forearm  is 

fully  extended,  and,  grasping  the  hand  in  one 

hand  while  the  thumb  and  fingers  of  the  other 

seize    the   elbow,   a  swaying   lateral    movement  T-fractureofthe 

lower  extrem- 

is  made.  If  the  fracture  involves  the  troch-  ity  of  the  hu. 
lear  surfaces  of  the  joint,  preternatural  lateral  merus. 
mobility  towards  the  side  implicated  will  be  found  to  exist. 
Crepitus  can  probably  also  be  elicited.  If  the  mobility  is 
equal  on  both  sides  and  is  not  arrested  abruptly,  but,  on 
the  other  hand,  it  seems  possible  to  turn  the  elbow  out- 
wards and  inwards  indefinitely,  the  fracture  is  either  above 
the  condyles  or  is  comminuted  (Fig.  47).  Valuable  indi- 
fig.  47-  cations  as   to  the  existence  and   position  of 

fracture  of  the  lower  end  of  the  humerus 
may  often  be  gotten  by  flexing  the  forearm 
to  a  right  angle,  holding  the  arm  firmly, 
and  thrusting  the  wrist  backward  with  a 
Comminuted  fract-  movement  which,  if  made  forcibly,  would 
ure  of  the  lower    tend  to  dislocate  the  forearm  backward;  and 

extremity   of    the 

humerus.  the  reverse,  made  by  traction  upon  the  hand 

while  the  arm  is  held  firm,  which  would  tend  to  dislocate 
the  forearm  forward.  In  thinly  covered  elbows,  particu- 
larly of  children,  in  which  the  signs  of  fracture   are   not  so 


J 2  A    CLINICAL    TREATISE    ON  FRACTURES. 

obscure,  the  in: mediate  deformity  resulting  from  the  injury 
often  gives  a  probable  clue  to  the  nature  of  the  latter,  and, 
moreover,  projecting  fragments  may  not  infrequently  be  felt 
beneath  the  skin  which  indicate  the  general  line  of  fracture. 

In  distinguishing  supracondyloid  fracture  from  fracture 
of  either  the  internal  or  external  condyle  the  important 
landmark,  the  relation  the  condyles  bear  to  the  olecranon, 
must  be  carefully  observed.  In  supracondyloid  fractures 
these  relations  are  not  disturbed.  Prominence  of  the  olec- 
ranon too,  frequently  found  in  supracondyloid  fracture,  is 
a  symptom  rarely  seen  in  fractures  of  either  external  or 
internal  condyle.  The  deformity  assumed  in  supracondy- 
loid fracture  is  usually  anterior  bowing  of  the  lower  end  of 
the  humerus  with  overriding  of  the  lower  fragment  behind 
the  upper  fragment,  thus  simulating  backward  luxation  at 
the  elbow-joint.  But  the  plane  of  fracture  being  at  times 
laterally  oblique,  will,  according  to  the  direction  of  this 
obliquity,  cause  external  or  internal  lateral  deviation  of  the 
elbow-joint,  displacing  it  well  inside  or  outside  of  the 
humeral  axis.  Again,  in  many  such  fractures  there  is  so 
little  deformity  that  the  natural  bony  contour  of  the  elbow- 
joint  is  modified  to  such  a  slight  extent  as  to  be  completely 
masked  by  the  swelling. 

Treatment. — An  anterior  splint  (Fig.  48)  which  is 
right-angled  or  obtuse-angled  is  applicable  for  most  cases. 
As  the  former  is  so  much  more  comfortable  for  the  patient 
if  he  is  up  and  about,  it  should,  if  found  to  fulfil  suffi- 
ciently the  indications,  have  the  preference.  Such  a  splint 
should    have    a  width   approximately    that    of   the    diameter 


FRACTURES    OF    THE    UPPER   EXTREMITY.  73 

of  the  elbow-joint,  and  should  extend  from  the  upper  part 
of  the  arm  to  the  tips  of  the  fingers.  Certain  precautions 
are  necessary  in  the  applica-  FlG    3 

tion  of  this  splint.  Care 
must  be  taken  that  the  bend 
of  the  elbow  does  not  receive 
undue  pressure  from  the 
angle  of  the  splint ;  the  splint 

.         111  -1  11     1  •  Anterior  right-angled  splint. 

should  be  so  bevelled  at  its 

upper  inner  corner  that  it  will  not  press  upon  the  integument 
of  the  chest  ;  and  the  sling  should  be  so  contrived  as  not 
to  risk  pressure-paralysis,  because  the  dressing  is  heavy. 
The  short  splint  sometimes  used  in  conjunction  with  the 
internal  right-angled  or  anterior  right-angled  splint  is  rarely 
needed.  Any  tendency  to  displacement  which  occurs  after 
the  latter  has  been  applied  may  be  best  corrected  by  a  care- 
fully adapted  cardboard  cap. 

In  applying  the  anterior  right-angled  splint,  it  must  be 
borne  in  mind  that  in  order  to  make  two  flat  boards,  joined 
to  one  another  at  a  right  angle,  adapt  themselves  nicely 
to  the  contour  of  the  arm  and  forearm  flexed  at  a  similar 
angle,  the  splint  must  be  carefully  adjusted.  In  order  that 
this  may  be  done  the  more  intelligently,  the  general  contour 
of  the  anterior  aspect  of  the  arm  and  forearm  as  it  appears 
in  profile  may  be  studied  with  advantage.  The  anterior 
profile  of  the  arm  presents  a  generally  straight  plane, 
though  there  may  be  a  muscular  swell  at  its  upper  portion 
and  another  at  its  middle.  The  bend  at  the  elbow  when 
the  hand  is  in  a  state  of  supination,  a  position  necessitated 


74  A    CLINICAL    TREATISE    ON  FRACTURES. 

by  the  anterior  splint,  is  an  easy,  rounded  curve;  while  the 
line  of  the  forearm  from  the  elbow  to  the  tips  of  the  fingers 
presents  in  profile  a  long  concavity  looking  upward.  The 
pad  of  oakum  having  been  so  placed  on  the  splint  that  it 
will  correspond  as  nearly  as  possible  to  this  very  irregular 
form  of  the  arm  and  forearm,  and  the  sharp  angle  of  the 
wooden  joint  sufficiently  covered  to  prevent  any  undue 
pressure  at  the  bend  of  the  elbow,  the  splint  is  tried  on; 
that  is,  it  is  held  in  the  position  which  it  is  to  be  made  to 
occupy,  and  careful  inspection  is  made  to  ascertain  if  it 
gives  even  and  equable  support  throughout  its  length.  If 
the  bend  of  the  elbow  appears  to  get  too  much  pressure,  a 
little  more  oakum  should  be  insinuated  beneath  the  lint  cov- 
ering just  above  and  below  the  latter.  It  will  now  usually 
be  found  for  the  first  time  that  the  splint  is  much  too  long; 
the  forearm  portion,  which,  measured  upon  the  sound  limb, 
was  made  to  extend  to  the  tips  of  the  fingers,  will  now 
probably  project  two  inches  beyond  the  tips  of  the  fingers. 
The  arm  portion  will  probably  be  in  very  imperfect  contact 
with  the  arm,  and  also  too  long.  In  order  to  avoid  these 
defects  the  splint  should  be  sawn  off  to  the  proper  dimen- 
sions before  the  padding  is  retained  with  the  bandage.  The 
most  common  cause  for  splint-sore  at  the  anterior  bend  of 
the  elbow  is  so  easily  prevented  by  the  simplest  precaution 
that  it  deserves  mention.  In  the  application  of  the  retain- 
ing bandage  to  the  hand  and  forearm  the  arm  portion  of  the 
splint  is  frequently  allowed  to  droop  forward,  its  upper 
extremity  being  removed  from  the  arm  a  distance  corre- 
sponding  to    the   degree   of  extension    at    the   elbow-joint. 


FRACTURES    OF   THE    UPPER   EXTREMITY.  ?$ 

When  the  bandage  reaches  the  elbow  the  forward  displace- 
ment of  the  splint  is  overcome,  and  in  so  doing  its  angle  is 
pressed  with  the  force  of  a  lever  into  the  bend  of  the  elbow. 
No  integument  will  stand  this.  The  splint  should,  there- 
fore, be  held  accurately  in  position  at  the  hand,  the  elbow, 
and  the  shoulder  during  the  application  of  the  retaining 
bandage.  As  a  limb  hangs  very  heavily  with  this  splint 
applied,  a  broad  handkerchief-sling  extending  from  the 
fingers  to  the  elbow  should  give  comfortable  support,  and 
in  order  to  encourage  the  patient  to  allow  the  arm  to  hang 
completely  relaxed  the  sling  should  be  padded  at  the  back 
of  the  neck  with  sufficient  thicknesses  of  lint  to  distribute 
the  pressure  at  this  point.  In  many  cases  of  fracture  of 
the  external  condyle  and  of  supracondyloid  fracture  the 
deformity  will  be  found  to  be  very  fully  corrected  by  the  use 
of  the  internal  right-angled  splint.  It  is  so  much  more 
comfortable  to  the  patient,  and  is  so  much  less  likely  to 
give  trouble,  either  by  becoming  disarranged  or  by  causing 
pressure-sores,  that  it  should  have  the  preference,  if  it  is 
found  to  retain  the  fragments  in  good  apposition.  On  the 
second  day  the  dressing  should  be  removed,  the  skin  bathed 
with  alcohol  and  carefully  inspected  at  every  point.  In 
reapplying  the  dressing,  the  bandage  on  this  occasion  may 
be  applied  with  a  little  more  tension  than  at  the  first  dress- 
ing. It  is  not  desirable,  as  a  rule,  to  make  passive  motion 
at  this,  the  second,  dressing.  Succeeding  changes  should  be 
made  every  five  days.  One  complete  extension  and  one 
complete  flexion,  one  movement  of  pronation  and  a  return 
to  the  state  of  supination,  are  the  passive  movements  which 


j6  A    CLINICAL    TREATISE    OX  FRACTURES. 

should   be   conducted,    and   the}-  are  very   rarely  contraindi- 
cated  by  any  tendency  of  the  fragments  to  become  displaced. 

Though  the  time  required  for  union  of  fractures  of  the 
elbow  varies  somewhat  with  the  nature  of  the  fracture, 
a  period  of  four  weeks  is  in  most  cases  long  enough  for  the 
fragments  to  be  at  least  safely  if  not  firmly  joined.  Another 
fortnight,  during  which  careful  attention  is  paid  to  the 
restoration  of  function,  is  usually  all  that  is  required  in  the 
management  of  the  case. 

It  is  unfortunate  that  in  fracture  about  the  elbow-joint, 
a  joint  so  prone  to  rigidity  after  injury,  early  passive  motion 
cannot  always  be  employed  without  risk  of  disturbing  the 
fragments.  It  is,  however,  so  important  a  part  of  the 
treatment  in  preventing  rigidity  and  in  restoring  function 
that  it  should  be  attempted  in  every  case,  and  abandoned 
onlv  on  the  positive  evidence  that  it  does  disturb  the 
fragments.  In  many  cases  rough  handling  would  disturb 
them,  while  by  maintaining  the  utmost  gentleness,  by 
securing  perfect  muscular  relaxation,  by  getting  the  con- 
fidence of  the  patient,  and  assuring  him  that  no  sudden 
or  forcible  movements  will  be  made,  one  complete  move- 
ment as  detailed  above  may  be  satisfactorily  performed  at 
the  second  dressing;  and  if  the  supporting  hand  at  the 
elbow  feels  no  crepitus,  no  mobility,  nor  change  in  the  posi- 
tion of  the  fragments,  these  movements  may  be  conducted 
at  each  succeeding  dressing,  in  many  cases  without  in 
the  least  retarding  union.  I  have  rarely  found  difficulty 
in  so  adjusting  the  fragments  as  to  correct  any  tendency 
to  overriding.       The  practice  of   overcoming  this   tendency 


FRACTURES    OF   THE    UPPER   EXTREMITY. 


77 


in  certain  refractory  cases  by  the  suspension  of  a  weight 
of  two  or  three  pounds  hung  on  the  elbow,  seems  to  rely 
too  much  upon  the  probability  of  the  patient's  maintaining 
for  a  large  part  of  the  day  an  attitude  which  will  make 
the  weight  act  efficiently.  An  individual  with  a  broken 
elbow  being  unable  to  work,  is  likely  to  recline  a  great  deal 
on  a  lounge  or  on  a  bed,  and  when  thus  recumbent  he  will 
probablv  keep  his  arm  across  his  chest  or  try  to  make  him- 
self comfortable  in  some  other  way,  while  he  gets  rid  of  the 
weight  either  by  placing  it  beside  him  or  by  removing  it 
altogether  between  the  professional  visits. 

Fractures  of  the  Shaft  of  the  Humerus.— Fractures  of 
the    shaft   of  the   humerus   are 
more    frequently    produced    by 
indirect    than    direct    violence. 
Thev  may  also  be  produced  by 
muscular  action  ;  and  although 
the     latter      is     an     infrequent 
cause,    the    humerus    is,   of  the 
long  bones,  the  one  most  liable 
to    yield    to     it.        Several    in- 
stances of  fractures  produced  in 
this  way  have   come  under  my 
observation,  among  them  one  in 
a  voung  man  who,  while  throw- 
ing a  baseball,  fractured  the  mid- 
dle third  of  his  right  humerus. 
For  another,  a  large,  muscular  colored  man  was  injured  in  a 
similar  manner  by  directing  a  blow  with  his  fist  which  failed 


Skiagraph    of    oblique   fracture    of   the 
shaft  of  the  humerus. 


7 8  A    CLINICAL    TREATISE    OX  FRACTURES. 

to  strike.  A  third  occurred  in  a  woman  fifty-five  years  of  age, 
who  sustained  a  fracture  high  up  in  the  shaft  of  her  right 
humerus  while  lifting  a  tub  of  water  from  a  chair  to  the  floor. 
Such  fractures  are  more  commonly  oblique  (Figs.  49 
and  50)  than  transverse  (Fig.  51).      While  anterior  bowing 


Skiagr&ph  of  oblique  fracture  of  the  shaft  of  the  humerus. 

is  the  more  frequent  displacement  (Fig.  52),  bowing  in  any 
direction  is  quite  possible,  and  is  caused  by  overlapping 
and  tilting  of  the  fragments  according  to  the  direction  of 
the  line  of  fracture  and  the  inclination  of  its  plane.  In 
some  transverse  fractures  of  the  shaft  the  bowing  at  the 
seat  of  fracture  seems  influenced  in  its  direction  wholly  by 
the  manner  in  which  the  forearm  happens  to  be  supported, 
the  direction  frequently  being  observed  to  change  in  a 
moment  from  anterior  to  internal  or  external  lateral,  or 
posterior  bowing. 

"While,  therefore,  the  deformity  following  fracture  of  the 
shaft  of  the  humerus  is  often  variable  or  dependent  upon 
the  direction  in  which  the  fragments  were  forced  by  the 
injury,  the  relation  which   the  fracture  bears  to  the  insertion 


FRACTURES    OF   THE    UPPER   EXTREMITY. 


79 


ox  certain  muscles  will  at  times  be  found  to  exert  an  influ- 
ence ;  thus,  if  the  fracture  occur  above  the  insertion  of  the 
fig.  si.  deltoid   or  below  the  in- 

sertion of  the  pectoralis 
major,  teres  major,  and 
latissimus  dorsi  muscles, 
the  upper  fragment  will 
be  drawn  upward  and  for- 
ward, while  the  lower 
fragment  is  tilted  inward. 
In  the  middle  third  of 
Fig.  52. 


Skiagraph  of  transverse  fracture  of  the  middle         Recent  fracture  of  the  shaft  of  the 
third  of  the  humerus.  humerus. 

the  shaft  below  the  insertion  of  the  deltoid  muscle,  muscular 
action  usually  exerts  less  influence.  As  has  been  stated, 
bowing  in  any  direction  is  observed  with  more  or  less  short- 
ening in  the  length  of  the  arm.  At  the  lower  third  muscular 
action  seldom  exercises  any  influence  on  the  direction  and 
character  of  any  displacement  which  may  exist. 

Diagnosis. — Loss  of  natural    contour  of  the   arm  with 


8o  A    CLINICAL    TREATISE    ON  FRACTURES. 

bowing  in  some  direction,  moderate  pain,  and  complete  loss 
of  power,  accompanied  by  free  and  universal  mobility  with 
or  without  crepitus,  indicate  at  once  the  existence  of  fracture. 
Treatment. — The  indications  for  treatment  of  fractures 
in  the  shaft  of  the  humerus  are  mainly  the  accurate  coapta- 
tion of  the  fragments  and  their  retention  in  a  state  of  abso- 
lute fixation.  As  there  is  usually  little  tendency  of  any 
deformity  to  relapse  after  it  has  been  properly  corrected, 
the  most  important  drawback  to  guard  against  is  motion  at 
the  seat  of  fracture.  Emphasis  may  well  be  laid  upon  this, 
as  ununited  fracture  of  the  shaft  of  the  humerus  is  not  very 
uncommon.  Perfect  fixation  cannot  be  depended  upon  with 
any  dressing  that  does  not  control  the  shoulder-joint.  An 
internal  right-angled  splint,  therefore,  supplemented  by  the 
use  of  a  shoulder-cap,  is  a  simple  dressing,  and  is  very  gen- 
erally applicable.  An  internal  right-angled  splint  extending 
from  the  axilla  to  the  tips  of  the  fingers,  of  a  width  corre- 
sponding to  the  diameter  of  the  arm,  should  be  prepared 
by  retaining  with  a  bandage  upon  its  surface  a  mass  of 
oakum,  which  should  vary  in  thickness  at  three  points. 
The  arm  portion  of  the  splint  must  not  be  so  long  that  its 
upper  extremity  will  be  unduly  thrust  into  the  axilla  when 
the  arm  is  brought  to  the  side  of  the  body,  lest  the  integu- 
ment or  the  structures  beneath  be  damaged  or  the  circulation 
in  the  arm  interfered  with.  From  the  upper  extremity  of 
the  arm  to  the  elbow  a  mass  of  oakum  is  placed  which 
when  compressed  will  make  a  comfortable  resting-place  for 
the  arm  and  elbow,  particularly  avoiding  any  pressure  upon 
the  internal   condvle  of  the   humerus.      In  order  further  to 


FRACTURES    OF   THE    UPPER   EXTREMITY.  8 1 

protect  this  very  sensitive  point  from  pressure,  and  also  to 
conform  to  the  natural  arch  of  the  forearm,  the  quantity  of 
padding  from  the  elbow  to  the  wrist  should  be  considerably 
increased  in  bulk.  At  the  palm  of  the  hand  the  oakum 
should  assume  a  somewhat  dome-shaped  form,  in  order  to 
adapt  itself  to  the  latter.  To  get,  as  elsewhere,  the  best 
effect  of  the  elasticity  of  the  oakum,  it  should  not  be  pressed 
upon  the  splint  too  firmly  with  the  bandage.  Upon  the 
splint  thus  prepared  is  placed  a  single  layer  of  patent  lint 
or  canton-flannel,  cut  to  correspond  in  form  to  the  right- 
angled  splint.  The  limb  is  then  placed  upon  the  splint 
and,  carefully  inspecting  the  seat  of  fracture  and  making 
gentle  pressure  upon  it  with  the  hand  about  equal  to  that 
which  will  presently  be  made  by  the  retaining  bandage, 
any  displacement  which  exists  should  be  overcome.  If  the 
effect  from  padding  is  found  insufficient,  more  oakum  should 
be  insinuated  beneath  the  lint  covering.  If  the  internal 
condyle  seems  to  be  getting  too  much  pressure  when  the 
elbow  is  pressed  upon,  a  small  ring  of  oakum  may  be  in- 
serted beneath  the  lint  lining  to  protect  it.  In  order  to 
prevent  contact  of  the  skin  surfaces,  small  pledgets  of  cotton 
should  be  inserted  between  each  finger  ;  and,  if  the  forearm 
is  fleshy,  also  in  the  fold  at  the  bend  of  the  elbow.  While 
an  assistant,  or,  better,  two  assistants,  seize  respectively  the 
upper  extremity  of  the  splint,  holding  it  firmly  to  the  arm, 
and  the  lower  extremity  held  steadily  with  sufficient  support 
given  to  the  fingers  to  keep  the  hand  in  proper  place,  the 
retaining  bandage,  extending  from  the  tips  of  the  fingers 
to  the  upper  extremity  of  the  splint,   is  applied.     Then  a 


82  A    CLINICAL    TREATISE    ON  FRACTURES. 

heavy  cardboard  shoulder-cap  should  be  so  modelled  that  it 
will  cover  the  entire  shoulder,  and,  extending  down  the  arm 
to  the  elbow-joint,  will  reach  the  margins  of  the  splint  in 
front  and  at  the  back  of  the  arm.  It  should  be  cut  from 
cardboard  one-eighth  inch  thick,  and  the  upper  portion 
should  be  so  scored  that  it  is  possible  to  adapt  it  neatly  to 
the  rotundity  of  the  shoulder.  When  cut  into  this  form  it 
is  immersed  for  a  moment  in  boiling  water,  and  immediately 
mopped  as  dry  as  possible  with  a  towel.  While  the  limb 
with  the  internal  right-angled  splint  in  place  is  held  away 
from  the  trunk  just  far  enough  to  allow  of  the  passage  of 
the  roller  bandage,  the  cardboard  cap,  nicely  adapted  to  the 
form  of  the  arm  and  shoulder  with  four  layers  of  canton- 
flannel  or  patent  lint  lining  it,  is  retained  by  spiral  turns 
of  a  bandage  to  the  arm  and  inner  splint  as  far  up  as  the 
extremity  of  the  latter  extends.  At  this  point  the  retaining 
bandage  becomes  an  ascending  spica  of  the  shoulder  to 
retain  the  cap  properly  in  position.  The  following  day 
this  latter  part  of  the  dressing  is  removed,  the  internal 
right-angled  splint,  if  found  to  be  entirely  comfortable, 
remaining  undisturbed.  The  cardboard  cap  being  now  dry, 
can  be  firmly  fixed  to  the  arm  portion  of  the  internal  right- 
angled  splint  by  broad  strips  of  rubber  adhesive  plaster,  sup- 
plemented by  the  spiral  turns  of  a  bandage  and  ascending 
spica  of  the  shoulder.  By  this  dressing  the  entire  upper 
extremity  will  be  found  to  remain  in  a  state  of  absolute 
immobility;  and  as  change  of  such  a  formidable  appliance 
involves  considerable  movement  of  the  fracture,  it  may  be 
allowed  to  remain  undisturbed,   provided    no  discomfort  at 


FRACTURES   OF   THE    UPPER   EXTREMITY.  83 

any  point  is  complained  of,  for  a  week  or  ten  days.  At  the 
end  of  this  time  the  whole  dressing  is  to  be  removed, 
the  skin  carefully  bathed  with  alcohol,  and  the  shoulder-, 
elbow-,  wrist-,  and  finger-joints  all  made  to  execute  their 
natural  movements.  The  dressing  is  then  reapplied,  and 
if  it  is  found  still  to  give  sufficient  support  everywhere  to 
prevent  any  motion  at  the  seat  of  fracture,  it  may  now  remain 
undisturbed  for  two  weeks.  The  dressing  should  be  retained 
for  one  week  after  the  fracture  is  found  to  have  united, 
which  it  usually  does  in  from  three  and  a  half  to  four  weeks; 
after  this  the  cardboard  cap  alone  may  be  used,  discarding 
the  internal  right-angled  splint.  Massage  and  gentle  exer- 
cises for  two  weeks   longer  conclude  the  treatment. 

At  times,  when  it  is  desirable  that  the  patient  should  be 
kept  a  few  days  or  a  week  in  the  recumbent  posture,  no 
splint  need  be  used  during  the  early  part  of  the  treatment, 
but  the  arm  may  be  allowed  to  rest  in  a  comfortable  position 
upon  a  pillow.  Such  a  course  as  preliminary  to  the  appli- 
cation of  a  fracture  dressing  becomes  especially  applicable 
when  there  is  great  contusion  of  the  soft  parts  or  extensive 
extravasation  of  blood. 

Fractures  of  the  Upper  Extremity  of  the  Humerus. 
— Fractures  of  the  upper  extremity  of  the  humerus  include 
those  of  the  surgical  neck  and  those  of  the  anatomical 
neck.  Fractures  of  the  anatomical  neck  involve  the  bone 
within  the  capsule,  as  do  also  those  extending  in  various 
directions  through  the  head  of  the  bone.  The  tuberosities 
may  be  detached  or  epiphyseal  separations  may  occur  during 
early  periods  of  life.     In  advanced  age  the  structural  chanees 


84  A    CLINICAL    TREATISE    ON  FRACTURES. 

occurring  in  this  portion  of  the  bone  render  it  increasingly 
liable  to  fracture.  Fractures  of  the  upper  extremity  of  the 
humerus  are  caused  by  falls  directly  upon  the  shoulder  or 
crushing  forces  applied  to  the  trunk.  Such  constitute  the 
more  common  applications  of  direct  violence.  Fracture  of 
a  tuberosity  of  the  humerus  is  usually  the  result  of  direct 
violence.  Falls  upon  the  hand  or  elbow  may  fracture  the 
upper  extremity  of  the  humerus  by  violence  indirectly 
applied.  The  bone  may  be  broken  through  the  surgical 
neck  in  efforts  at  reduction  of  old  dislocations  of  the 
shoulder-joint.  Fracture  through  the  surgical  neck  of  the 
bone,  either  approximately  transverse  or  with  an  obliquity 
of  its  plane  which  carries  it  more  or  less  down  the  shaft,  is 
by  far  the  most  common  fracture  of  the  upper  extremity  of 
the  humerus.  Fractures  of  the  head  are  usually  com- 
minuted, and  are  rare.  Fractures  of  the  anatomical  neck 
are  likewise  rare.  Fracture  of  a  tuberosity  occurs  as  a 
complication  to  dislocation  of  the  shoulder  more  frequently 
than  as  a  simple  injury. 

Diagnosis. — Pain,  swelling,  loss  of  power,  inability  .to 
perform  any  movement  of  the  shoulder-joint,  particularly 
that  of  elevation,  are  signs  which,  while  not  characteristic 
of  this  particular  lesion,  may  point  to  its  existence,  if  injury 
to  other  bones  contributing  to  the  construction  of  the 
shoulder-joint  has  been  eliminated.  As  fractures  in  this 
locality  are  extremely  difficult  to  locate  even  if  their 
presence  has  been  determined,  and  as  the  somewhat  for- 
cible manipulations  which  must  necessarily  be  made  cause 
much   pain,  an    anaesthetic   should  always  be  administered, 


FRACTURES    OF   THE    UPPER   EXTREMITY.  85 

unless  some  special  contraindication  to  its  use  exists.  Seiz- 
ino-  the  slioulder-ioint  over  the  head  of  the  humerus  with  one 
hand,  the  shaft  of  the  bone  along  with  the  elbow-joint  is  ro- 
tated through  a  large  arc;  during  this  manoeuvre  crepitus  will 
probably  be  elicited.  The  upper  extremity  of  the  bone  may 
or  may  not  be  felt  to  rotate  independently  of  the  head.  If 
the  subject  is  fleshy— and  these  fractures  occur  more  fre- 
quently in  fleshy  subjects — very  little  clue  may  be  obtained 
as  to  the  exact  locality  of  the  fracture  by  this  manipu- 
lation. Seizing  the  shoulder  while  the  arm  is  forcibly 
thrust  upward  by  pushing  the  elbow  in  the  direction  of  the 
humeral  axis  may  demonstrate  some  mobility  in  this  direc- 
tion and  crepitus;  and  flattening  of  the  shoulder,  which 
perhaps  was  present,  disappears  and  the  normal  contour  is 
restored.  Forcible  traction  downward  will,  under  these  cir- 
cumstances, reproduce  the  deformity  and  crepitus  will  be 
again  felt.  While  these  will  usually  be  found  reliable  means 
for  ascertaining  the  existence  of  fracture  of  the  neck,  they 
show  little  which  can  be  depended  upon  to  indicate  what 
portion  of  the  neck  the  latter  has  involved.  Fortunately, 
the  importance  of  distinguishing  between  these  locations  is 
not  great  so  far  as  treatment  is  concerned,  though  having 
a  bearing  upon  prognosis. 

Fracture  of  the  Surgical  Neck  of  the  Humerus. — 
Fracture  at  this  point  may  be  produced  by  direct  or  indi- 
rect violence  of  a  kind  which,  slightly  modified,  is  capable 
of  fracturing  the  shaft  on  the  one  hand  or  the  anatomical 
neck  on  the  other.  Falls  upon  the  shoulder  or  falls  upon 
the  hand;  direct  blows,   as  the  kick  of  a  horse;  or  twisting, 


86  A    CLINICAL    TREATISE    ON  FRACTURES. 

wrenching  strains,  as  those  applied  in  efforts  to  reduce  old 
dislocations  of  the  shoulder-joint,  are  all  liable  to  cause  the 
injury. 

The  line  of  fracture  involving  the  surgical  neck  of  the. 
humerus  is  outside  of  the  capsular  ligament  of  the  shoulder- 
joint  and  below  the  tuberosities.  As,  therefore,  it  is  below 
the  insertion  of  the  muscles  inserted  into  the  latter — sub- 
scapularis,  infraspinatus,  and  teres  minor — the  upper  frag- 
ment, which  is  the  head  of  the  humerus,  may  be  subjected 
to  extreme  rotation  and  abduction.  The  lower  fragment, 
which  is  the  shaft  of  the  bone,  losing  its  support  at  the 
shoulder-joint,  may  be  drawn  inward  and  tilted  toward  the 
trunk  principally  by  the  action  of  the  pectoral  is  major,  latis- 
simus  dorsi,  teres  major,  and  deltoid  muscles.  The  charac- 
teristic deformity  resulting  is  more  or  less  flattening  of  the 
shoulder  accompanied  by  an  outward  inclination  of  the  arm, 
resembling,  but  less  marked  than,  that  accompanying  sub- 
glenoid luxation. 

Fracture  of  the  anatomical  neck  of  the  humerus, 
which  is  an  intracapsular  fracture,  can  in  thin  subjects  be 
distinguished  from  fracture  of  the  surgical  neck;  but  usually 
only  with  the  aid  of  an  anaesthetic.  As  fracture  at  this 
point  deprives  the  head  of  the  bone  of  blood-supply,  the 
latter  remains  either  as  an  inert  foreign  body,  or,  becoming 
necrotic,  causes  suppuration  in  the  joint,  necessitating 
removal.  On  the  other  hand,  fortunately  for  the  future 
function  of  the  limb,  the  force  producing  the  fracture  may 
cause  firm  impaction  of  the  fragments.  On  purely  theo- 
retical  grounds,   the    less   such    a  fracture    is   disturbed  the 


FRACTURES    OF   THE    UPPER   EXTREMITY.  8/ 

better,  for  even  moderate  manipulations  made  to  determine 

the  character  of  the  injury  might  readily  relieve  the  impac- 
tion and  make  the  fracture  complete.  As  the  diagnosis, 
however,  of  fracture  involving  the  anatomical  neck  is  not 
easv,  given  a  fracture  in  which  the  deformity  is  inappre- 
ciable and  in  which  no  preternatural  mobility  or  crepitus 
can  be  elicited,  the  evidences  which  would  render  the  exist- 
ence and  nature  of  the  injury  conclusive  are  wanting;  and 
the  injunction  occasionally  heard,  not  to  risk  disturbing  the 
impaction  of  an  impacted  fracture  at  the  anatomical  neck 
of  the  humerus,  is  unreasonable  unless,  indeed,  a  particu- 
larly clear  skiagraph  should  have  demonstrated  the  lesion. 

Diagnosis. — The  examination  should,  if  possible,  be 
made  under  ether.  Conducting  the  rotary  movement,  crep- 
itus will  probably  be  readily  elicited,  and,  seizing  the 
shoulder-joint,  the  head  and  neck  of  the  bone  can  easily 
be  sufficiently  isolated,  even  through  a  mass  of  fat,  to  feel 
that  they  remain  motionless  while  the  shaft  is  rotated. 
The  slight  deflection  of  the  axis  of  the  arm  outward  will 
be  found  to  be  readily  corrected  if  the  fist  is  placed  in  the 
axilla  and  the  elbow  carried  to  the  trunk;  but  as  this 
deformity  is  produced  by  the  combined  action  of  the  trunk 
muscles  attached  to  the  upper  end  of  the  lower  fragment, 
it  is  reproduced  the  moment  the  pressure  is  released. 

Fracture  of  the  head  of  the  humerus,  as  already  stated, 
is  usually  comminuted,  caused  in  most  cases  by  direct 
impact  upon  the  shoulder;  the  bone  being  crushed  by  the 
counter-resistance  of  the  glenoid  cavity.  It  is  so  rare  an 
injury  and  may  be   so   difficult  or  impossible   to  detect  that 


8S  A    CLINICAL    TREATISE    ON  FRACTURES. 

its  existence  is  more  than  likely  to  be  overlooked.  There 
may  be  no  deformity,  no  crepitus;  and  the  symptoms  of 
pain  and  disability,  being  common  to  the  several  other 
fractures  in  this  locality,  furnish  little  help  in  making  a 
diagnosis. 

Fracture  of  the  Tuberosities  of  the  Humerus. — Any 
tuberosity  may  be  chipped  off  by  direct  impact,  or  it  may 
be  torn  away  when  the  head  of  the  bone  is  dislocated. 
The  presence  of  such  a  fracture  may  be  discovered,.by  pal- 
pation, though  in  fleshy  subjects  it  is  likely  to  escape  notice 
altogether.  The  injury  is  to  be  recognized  by  the  continuity 
of  the  shaft  with  the  head  of  the  bone,  and  the  presence 
of  an  abnormal  depression  below  the  acromion,  where  the 
detached  fragment  may  be  felt  if  the  subject  is  not  too 
fleshy. 

Epiphyseal  separation  of  the  upper  extremity  of  the 
humerus  is  uncommon.  Twisting  strains  and  forcing  the 
bone  in  any  direction  beyond  the  natural  limits  of  joint- 
motion  are  the  causes  usually  ascribed  as  producing  the 
injury.  As  the  separation  occurs  in  the  anatomical  neck 
of  the  bone,  if  loss  of  continuity  is  made  out  in  a  subject 
under  twenty  years  of  age,  the  lesion  may  be  regarded  as 
epiphyseal  separation.  The  symptoms  of  this  lesion  are, 
therefore,  precisely  those  of  fracture  of  the  anatomical  neck, 
except  that  there  is  no  bone  crepitus  if  the  separation  is 
purely  epiphyseal.  There  may  be  the  dry  creak  of  carti- 
laginous surfaces  rubbed  together;  or,  if  a  small  portion  of 
bone  is  detached  from  either  fragment,  faint  crepitus. 

Treatment  of  Fractures  of  the  Upper  Extremity 


FRACTURES    OF   THE    UPPER   EXTREMITY.  89 

OF  THE   HUMERUS. — As   the    indications   for   the    reduction 
and  general  management  of  all  the  more  common  fractures 
of  the  upper  extremity  of  the  humerus  are  similar  and  vary 
only  in  detail,  they  may  perhaps  well  be  considered  together. 
Fracture  of  the   surgical   neck   is  much   the  most  common 
of  them,   and  is  characterized,   as  already  stated,  by  adduc- 
tion of  the  upper  end  of  the  lower  fragment  and  inclination 
of  its  axis  outward.     The  elbow  will  thus  be  placed  some- 
what  away  from   the   trunk.     This  tendency  must  be   cor- 
rected, and,  what  is  of  more  importance,  must  be  prevented 
from  recurring,  by  carrying  the  upper  extremity  of  the  lower 
fragment  outward  to  a  line  which  will  as  accurately  as  pos- 
sible coapt  it  to  the  upper  fragment.     This  can  best  be  done 
by  placing  base  upward  in  the  axilla  a  pad  composed  of  a 
mass  of  oakum  wrapped  in  lint,  modelled  into  a  somewhat 
wedge-shaped  form,  and  of  a  thickness  which  is  found  suf- 
ficient for  the  purpose.     The  pad  so  placed  is  retained  by 
the  second  roller  of  Desault,  applied  in  the  following  manner: 
Fix  the  initial  extremity  of  the  roller  by  two  circular  turns, 
which  include  the  thorax  and  the  arm  on  the   injured  side. 
They  pass   over   the   head  of  the    humerus  and   under  the 
sound  axilla.     Descend  the  chest  and  arm  by  spirals,  over- 
lapping one-half.     These  turns  must  constantly  increase  in 
tension    until    the   elbow  is  reached,   when   the  bandage  is 
pinned.     The  spirals  may  somewhat  converge  on  the  sound 
side,   so  that    they    overlap    three-quarters   of    their   width. 
In  this  way  the  elbow  is  drawn  to  the  body  and  the  upper 
extremity   of    the    humerus    forced    outward    by  the    action 
of    the    low   spiral    turns,    which    press    the    shaft   of    the 


9°  A    CLINICAL    TREATISE    OX  FRACTURES. 

humerus  upon  the  pad,  as  upon  a  fulcrum.  As  the  upper 
fragment  seldom  requires  any  attention,  except  that  it  be 
controlled  as  far  as  possible  from  voluntary  or  involuntary 
muscular  efforts,  the  remaining  requirement  is  that  fixation 
should  be  maintained.  This  is  best  done  by  the  employ- 
ment of  a  nicely  fitting  cardboard  shoulder-cap  extending 
well  down  to  the  elbow.  It  is  very  desirable  that  this  cap 
should  have  been  moulded  and  thoroughly  dried  before  the 
application.  The  latter  may,  therefore,  be  delayed  for  a  day 
or  two  for  this  purpose  if  a  cap  already  prepared  is  not  at 
hand.  It  may  be  retained  bv  turns  of  a  bandage  extending- 
around  the  chest ;  but  a  more  secure  and  neat  method  is 
by  wide  rubber  adhesive  strips.  A  broad  handkerchief-sling 
supports  the  forearm  and  hand.  This  dressing,  if  entirely 
comfortable  to  the  patient,  may  be  allowed  to  remain  undis- 
turbed for  two  days,  when  it  should  be  removed,  elevating 
support  being  given  meanwhile  to  the  elbow,  and  the  skin 
bathed  with  alcohol  at  every  part  that  has  been  confined 
by  the  bandage.  After  this  change,  it  will  not  usuallv  be 
found  necessary  to  remove  and  reapply  at  less  intervals  than 
five  days  or  a  week.  In  many  cases  it  is  possible  to  begin 
passive  motion  at  the  shoulder-joint  early,  if  such  motion 
is  conducted  with  great  care  in  order  to  avoid  disturbance 
of  the  fracture.  As  there  is  much  tendency  to  rigidity  at 
this  joint,  early  motion  of  it  is  very  important,  and  it  must 
always  be  borne  in  mind  that  even  the  slightest  movement 
made  with  the  utmost  gentleness  and  gradually  increased 
at  each  dressing  will  prove  of  the  greatest  use  in  restoring 
function  after  the  fracture  has  united.      Seizing  the  upper 


FRACTURES    OF   THE    UPPER    EXTREMITY.  9 1 

portion  of  the  arm  with  the  left  hand  the  ringers  are  thrust 
into  the  axilla  and  the  upper  fragment  is  pressed  between 
them  and  the  thumb  in  order  to  make  it  follow,  if  possible, 
the  movements  of  the  lower  fragment  conducted  by  elevat- 
ing the  elbow.  At  the  end  of  four  weeks  union  will  have 
begun,  but  it  is  seldom  firm  before  six  weeks.  The  dressing 
should  be  discarded  ten  days  after  no  motion  can  be  detected 
at  the  seat  of  fracture.  For  the  succeeding  two  months, 
every  care,  by  the  employment  of  gentle  exercise  and  mas- 
sage, should  be  taken  to  prevent  permanent  disability,  for 
few  of  the  major  joints  seem  so  liable  to  be  neglected  by 
the  patient  if  he  is  not  carefully  supervised.  Paralysis  of 
the  deltoid,  an  occasional  complication  of  this  injury,  may 
be  caused  by  the  original  impact  producing  the  fracture, 
for  it  not  infrequently  follows  mere  contusions  at  the 
shoulder.  It  is  tardy  in  its  course  and  disappointing  in 
its  management.  Electricity  and  massage  are  the  agents 
which  prove  most  efficient  for  its  relief. 

Fractures  of  the  anatomical  neck  may  be  managed  in 
very  much  the  same  way  ;  but  the  necessity  of  forcing  the 
shaft  of  the  bone  outward  being  much  less  the  axillary  pad 
need  not  be  so  thick.  The  flattening  of  the  shoulder  which 
is  caused  by  drooping  of  the  arm  requires  elevation  of  the 
latter.  The  third  roller  of  Desault  will  best  accomplish 
this,  applied  in  the  following  manner :  Place  the  initial 
extremity  of  the  roller  under  the  axilla  on  the  sound  side, 
and  carry  it  obliquely  across  the  front  of  the  chest  to  the 
middle  of  the  summit  of  the  shoulder  on  the  injured  side. 
Down  behind  the  humerus,  and  parallel  with  it  to  the  elbow ; 


92  A    CLINICAL    TREATISE    ON  FRACTURES. 

under  the  latter,  and  across  the  front  of  the  chest  to  the 
axilla  on  the  sound  side,  where  the  initial  extremity  is  met 
and  fixed.  The  roller  now  passes  under  the  axilla,  obliquely 
across  the  back  to  the  middle  of  the  summit  of  the  shoulder 
on  the  injured  side.  Down  in  front  of  the  humerus,  and 
parallel  with  it  to  the  elbow  ;  under  the  elbow,  and  across 
the  back  to  the  axilla  on  the  sound  side,  which  completes 
one  entire  turn — an  anterior  and  a  posterior  triangle.  From 
this  point  it  emerges,  and  is  in  position  to  cross  the  front 
of  the  chest  to  the  shoulder  on  the  injured  side  as  before, 
and  descend  behind  the  humerus,  and  pass  under  the  elbow, 
back  again  to  the  axilla.  Another  posterior  turn  is  then 
made.  In  this  way  three  anterior  and  three  posterior  tri- 
angles are  formed,  which  exactly  repeat  each  other,  and  the 
end  of  the  roller  is  pinned  at  any  point  in  front.  Each 
intersection  also  must  be  secured  by  pins  or  adhesive  plaster, 
and  a  sling  to  support  the  forearm  and  hand  completes  the 
dressing. 

Fractures  of  the  head,  of  the  tuberosities,  or  epiphyseal 
separation  of  the  upper  extremity  of  the  humerus,  are  appro- 
priately treated  by  the  application  of  a  similar  dressing  to 
that  used  for  fractures  of  the  anatomical  neck. 

Non-union  of  fracture  of  the  anatomical  neck  does  not 
perhaps  occur  as  often  as  is  supposed.  Union,  however,  is 
likely  to  be  long  delayed,  but  ultimate  restoration  of  func- 
tion, partial  or  complete,  may  not  thereby  be  prevented. 
As  already  stated,  an  impacted  fracture  at  this  point,  unless 
the  impaction  be  relieved  by  the  manipulations  made  dur- 
ing the  examination,   may  readily  escape  detection,  for  fre- 


FRACTURES    OF   THE    UPPER   EXTREMITY.  93 

quently  no  sign  pointing  to  it  exists  which  is  not  also 
present  after  a  severe  contusion  or  sprain  of  the  shoulder- 
joint. 

Dislocation  of  the  detached  head  accompanying  this  fract- 
ure is  occasionally  met  with.  Through  what  process  this 
combined  lesion  occurs  it  is  difficult  to  demonstrate  ;  but 
it  is  reasonable  to  suppose  that  the  force  producing  the 
injury  fractures  the  bone  and  tears  the  capsular  ligament, 
and  permits  the  head  of  the  bone  to  be  easily  dislodged 
from  the  glenoid  cavity  and  tilted  out  by  the  lower  frag- 
ment. In  dealing  with  the  dislocated  detached  head  of  the 
bone,  the  first  consideration  relates  to  the  possibility  of 
replacing  it  by  manipulation.  This,  unfortunately,  can 
rarely  be  successfully  accomplished,  the  collapsed  capsular 
ligament  seldom  permitting  of  re-entry  through  its  tear. 
If  the  fragment  cannot  be  so  restored,  the  chance  of  estab- 
lishing a  new  shoulder-joint  by  articulation,  more  or  less 
perfect,  of  the  fractured  extremity  of  the  humerus  with  the 
glenoid  cavity  remains.  The  head  of  the  bone  may,  pro- 
vided it  causes  no  trouble,  be  ignored  as  an  inert  foreign 
body  ;  otherwise  it  should  be  removed.  Opening  the  shoul- 
der-joint and  replacing  it  is  a  practice  that  cannot  be 
advised  under  the  conditions  likely  to  obtain.  A  surgical 
injury  allied  to  this  is  the  occurrence  of  a  fracture  of  the 
shaft  or  neck  of  the  humerus  produced  by  efforts  made  to 
reduce  an  old  dislocation  at  the  shoulder-joint.  Such  a 
fracture,  particularly  if  high  up,  is  by  no  means  to  be  con- 
sidered a  surgical  calamity.  Like  other  accidents  which 
ma}*    result   from    this    procedure,    it    should    be    mentioned 


94 


A    CLINICAL    TREATISE    ON  FRACTURES. 


to  the  patient  beforehand  as  a  possibility.  Should  the  line 
of  fracture  fortunately  be  above  the  insertion  of  the  deltoid, 
no  attempt  at  fixation  is  indicated.  The  fracture  should 
remain  ununited  in  order  to  establish  a  false  joint  at  its 
seat. 

FRACTURES  OF  THE  SCAPULA. 

Fractures  of  this  bone  occur  in  four  principal  localities, 
and  may  be  so  divided  into  (i)  fractures  of  the  body,  (2) 
fractures  of  the  acromion  process,  (3)  fractures  of  the  cora- 
coid  process,   and  (4)  fractures  of  the  glenoid  cavity. 

(1)  Fracture  of  the  Body  of  the  Scapula. — The  line 
of  single  fracture  in  the  body  of  the  scapula  may  extend  in 
such  a  direction  that  only  the  lower  angle  is  separated  ;  it 
may  extend  obliquely  in  any  direction,  including  in  its 
course  the  spine  ;  or  it  may  involve  only  that  portion  of  the 
bone  above  the  spine.  The  part  most  commonly  fractured 
is  some  portion  of  the  broad,  thin  plate  below  the  spine 
(Fig.  53),   both  on   account  of   its    greater   exposure  to  the 

effects  of  blows  and  falls  and  because 
it  is  so  frail.  Almost  invariably 
broken  by  direct  violence,  this  por- 
tion of  the  body  is  frequently  the 
seat  of  comminuted  fracture.  The 
spine  being  structurally  the  strong- 
est part  of  the  bone,  seldom  yields 
to  direct,  indirect,  or  muscular  vio- 
lence, except  at  its  surgical  neck. 
From  this  point  outward  to  its  acromion  process  it  is  increas- 
ingly liable  to  fracture. 


Fig.  53. 


Fracture    of  the   body  of   the 
scapula. 


FRACTURES    OF   THE    UPPER   EXTREMITY.  95 

Diagnosis  of  fractures  of  the  body  of  this  bone  may 
occasionally  be  made  by  palpation,  especially  if  they  involve 
the  spine  and  are  accompanied  by  displacement.  Carrying 
the  fingers  along  the  spine,  particularly  in  thin  subjects,  even 
a  slight  deviation  from  its  natural  contour  is  felt.  Seizing 
the  bone  on  either  side  of  the  supposed  deformity,  crepitus 
may  be  elicited  together  with  slight  mobility.  Should  the 
fracture  involve  only  the  body  of  the  bone  below  the  spine, 
no  deformity  may  be  apparent,  and  yet  the  presence  of  fract- 
ure and  approximately  its  line  may  be  determined  by  the 
following  manipulations :  Carrying  the  elbow  well  back,  the 
inferior  angle  of  the  scapula  will  be  made  prominent  ;  and 
it  will  be  found  possible  to  thrust  three  fingers  of  the  other 
hand  well  under  the  bone,  in  many  subjects  as  far  as  an 
inch  and  a  half.  Good  control  of  it  is  obtained  in  this  way, 
and  it  will  be  found  very  easy  to  make  a  satisfactory  explor- 
ation of  its  whole  lower  surface  by  movements  with  one 
hand  and  counter-movements  with  the  other,  aided  by  a 
variety  of  motions  imparted  to  the  shoulder.  This  manip- 
ulation, although  I  have  never  seen  it  described,  is  a  very 
simple  and  effective  one  in  furnishing  positive  or  negative 
information  of  an  injury  which  is  likely  to  be  otherwise 
obscure. 

(2)  Fracture  of  the  coracoid  process  of  the  scapula 
as  a  simple  injury  is  of  so  rare  occurrence  that  it  hardly 
needs  consideration.  Many  of  the  separations  of  this  pro- 
cess which  are  recorded  are  epiphyseal.  Whether  it  is 
detached  by  fracture  of  bone  or  cartilage,  however,  has 
little  bearing  on  its  presence  or  its  management. 


96  A    CLINICAL    TREATISE    ON  FRACTURES. 

Diagnosis. — In  thin  subjects,  if  an  injury  about  the 
shoulder  is  unaccompanied  by  great  swelling,  the  coracoid 
process  can  be  felt  with  the  fingers.  If  fracture  is  present, 
this  process  will  be  felt  to  move  in  conjunction  with  the 
motions  of  the  humerus,  while  the  scapula  is  held  firm. 
The  slight  forward  displacement  of  the  shoulder  which 
accompanies  this  fracture  may  be  reduced  by  forcing  the 
head  of  the  humerus  backward  well  into  the  glenoid  cavity, 
to  recur  on  removing  the  pressure. 

(3)  Fracture  of  the  Acromion  Process  of  the  Scapula. 
— From  its  intimate  connection  with  the  clavicle,  the  acro- 
mion process  is  liable  to  fracture  from  any  force  which 
would  either  fracture  or  dislocate  the  acromial  end  of  the 
clavicle,  particularly  such  forces  as  blows  and  falls  upon  the 
shoulder.  It  may  be  fractured  anterior  to  the  acromiocla- 
vicular articulation,  through  and  involving  it  or  behind  it. 
Fracture  anterior  to  the  articulation  of  the  clavicle  is  an 
injury  which  is  unimportant  in  all  respects.  No  displace- 
ment occurs;  there  is  no  change  in  form  or  risk  of  inter- 
ference with  future  function  of  the  shoulder-joint;  and  .pro- 
viding the  accompanying  contusion  causes  no  paralysis  of 
the  deltoid  muscle,   no  complication  need  be  feared. 

Its  diagnosis  is  not  difficult;  but  as  the  movements  of 
the  shoulder-joint  necessary  for  its  detection  are  painful,  the 
examination  for  it,  as  well  as  for  other  fractures  in  this 
locality,  had  better  be  made,  if  possible,  during  anaesthesia. 
Having  eliminated  the  clavicle  from  injury,  and  the  sterno- 
clavicular articulation  being  found  intact,  crepitus  can 
usually   be   elicited    by   elevation    and    rotation    of  the    arm 


FRACTURES    OF   THE    UPPER   EXTREMITY.  g1/ 

while  the  fingers  of  the  other  hand  are  firmly  pressed  upon 
the  acromion.  As  already  stated,  deformity  is  slight  or 
absent,   especially  in  fleshy  subjects. 

If  the  fracture  includes  a  portion  of  the  articular  sur- 
face or  is  posterior  to  it,  there  may  be  enough  deformity  to 
be  felt  by  carrying  the  finger  along  the  spine  of  the  scapula, 
when,  the  point  of  fracture  being  reached,  a  slight  cleft  or 
depression  will  be  felt.  The  point  of  fracture  may  also  be 
accurately  located  by  free  movements  of  the  shoulder-joint 
in  various  directions  while  the  fingers  are  placed  at  differ- 
ent points  long  the  spine  of  the  scapula. 

Treatment  of  Fractures  of  the  Scapula. — The 
indications  for  treatment  of  fracture  involving  any  portion 
of  the  scapula  are  usually  simple.  In  the  large  proportion 
of  cases,  there  being  little  or  no  deformity  to  combat,  the 
simplest  kind  of  dressing  will  be  found  to  give  sufficient 
fixation  to  secure  the  occurrence  of  early  union.  This  is 
true  of  fractures  of  the  body  of  the  bone  and  of  its  proc- 
esses. The  arm  should  be  retained  at  the  side  by  the 
application  of  spiral  turns  of  the  broad  roller  bandage,  a 
broad  handkerchief-sling  supporting  the  hand  and  forearm. 
If  all  opposing  skin  surfaces  are  protected  by  single  layers 
of  lint,  the  dressing  will  prove  comfortable,  and  may  be 
retained  five  days  or  a  week  undisturbed.  At  the  end  of 
three  weeks  it  may  be  discarded.  If  there  is  drooping  of  the 
head  of  the  humerus  after  fracture  of  the  coracoid  process, 
the  position  maintained  by  Velpeau's  bandage  will  be  found 
the  one  which  best  corrects  tendency  to  this  condition.  In 
fractures  of  the  body,   especially  when  comminuted,   useful 


98  A    CLINICAL    TREATISE    ON  FRACTURES. 

support  to  the  fragments  will  be  obtained  by  the  employ- 
ment of  a  neatly  fitting  cardboard  shoulder-cap,  so  shaped 
that  it  will  extend  down  over  the  whole  bone.  This  can 
well  be  retained  by  the  Velpeau  bandage.  Since  after 
fracture  of  the  scapula  there  is  little  tendency  to  deformity, 
and  as  the  original  injury  has  not  unlikely  caused  either  a 
sprain  or  a  contusion  of  the  shoulder-joint,  early  passive 
movement  of  the  latter  is  practicable,  and  should  be  begun 
immediately.  These  movements  should  be  performed 
gently,  but  may  without  risk  be  given  considerable  lati- 
tude. 

FRACTURES    OF    THE    CLAVICLE. 

As  fractures  of  the  clavicle  are  often  far  from  satisfactory 
in  their  results,  either  because  they  unite  with  unsightly 
deformity,  or  by  delayed  union  cause  impairment  of  func- 
tion, through  rigidity  of  the  shoulder  by  long  disuse, 
or  by  failure  to  unite  altogether,  they  have  received  their 
full  share  of  surgical  thought  and  attention.  Though 
occasionally  broken  by  direct  violence,  which  causes  an 
approximately  transverse  fracture,  the  clavicle  is  more  fre- 
quently fractured  obliquely  by  force  indirectly  applied,  and 
in  some  instances  by  muscular  action.  Its  external  extrem- 
ity, usually  broken  by  direct  violence,  such  as  the  kick  of 
a  horse,  is  an  uncommon  seat  of  fracture.  In  describing  a 
fracture  which  is  of  such  frequent  occurrence,  the  subject 
can  only  be  properly  presented  by  sufficiently  emphasizing 
the  conditions  as  they  are  usually  found.  In  a  very  large 
proportion  of  instances  the  bone  is  fractured  in  its  middle 


FRACTURES   OF   THE    UPPER   EXTREMITY.  99 

third,  the  shoulder  is  drawn  forward  and  inward,  carrying 
down  with  it,  principally  by  gravity,  the  outer  fragment, 
which,  with  its  axis  deflected  backward,  overlaps  the  inner 
fragment.  These  alterations  in  the  position  of  the  outer 
fragment  cause  the  inner  fragment  to  be  relatively  elevated 
and  brought  forward  into  prominence:  and  it  is,  therefore, 
the  inner  fragment  which  always  appears  to  be,  but  is  not, 
chiefly  at  fault.  The  action  of  the  clavicular  insertion  of 
the  sternocleidomastoid  muscle,  which  has  always  been 
credited  with  elevating  the  inner  fragment,  has  in  reality,  I 
think,  little  effect.  The  evil  consequences  resulting  from  a 
continuance  of  this  characteristic  deformity  are  narrowing 
of  the  shoulder,  which  causes  deficient  purchase  for  the 
perfect  action  of  the  shoulder-joint;  a  sharp  bony  promi- 
nence upon  the  shoulder,  which  prevents  the  carrying  of 
loads  upon  it;  and,  finally,  especially  in  women,  whose  cos- 
tumes may  expose  the  neck,  a  lasting  defect  which,  justly 
or  unjustly,  reflects  upon  the  treatment.  The  cause  for 
ununited  fracture  is  mainly  want  of  fixation,  though  an 
extent  of  overlapping  which  brings  shaft  surfaces,  instead 
of  fractured  surfaces,  in  contact,  would  seem  to  exercise  an 
influence  in  certain  cases.  It  must  be  remembered  that  the 
deformity  alluded  to  above  is  excessive  deformity — deformity 
great  enough  either  to  be  very  noticeable  or  in  some  way  to 
interfere  with  the  functions  of  the  shoulder-joint  or  the 
upper  extremity.  But  the  clavicle  is  so  superficially  situ- 
ated beneath  the  integument  that  even  slight  loss  of  its 
natural  contour  can  be  plainly  felt  or  seen;  and  it  may 
therefore  be  fairly  stated  that  no  complete  fracture,   where 


100  A    CLINICAL    TREATISE    ON  FRACTURES. 

there  has  been  any  overlapping  at  the  outset,  will  unite 
with  the  fragments  in  such  ideal  apposition  that  slight 
deformity  will  not  remain. 

Diagnosis. — The  means  employed  for  the  detection  of 
fracture  of  the  clavicle,  either  at  its  more  common  seat,  the 
middle  third  of  the  bone,  or  at  its  sternal  or  acromial  end, 
are  the  same.  There  is  pain,  much  increased  on  attempt 
to  move  the  upper  extremity  ;  there  is  contusion  of  the 
integument  over  the  clavicle  in  the  exceptional  instances 
in  which  the  fracture  has  been  caused  by  direct  violence ; 
and  there  is  usually  sufficient  deformity  of  the  character 
above  described  to  be  plainly  apparent  on  inspection.  Pal- 
pation is  made  over  the  length  of  the  bone  with  the  object 
of  both  noting  any  loss  of  contour  which  may  exist  and  of 
locating,  if  possible,  the  seat  of  fracture.  In  young  children 
such  an  examination  is  often  all  that  is  necessary,  for  their 
outcries  cause  convulsive  respiratory  movements  which 
disturb  the  fragments  and  produce  distinct  crepitus.  In 
conducting  a  further  examination  in  adults,  the  patient 
should  lie  upon  the  back  without  a  pillow.  In  this  posi- 
tion the  whole  shoulder  will  usually  become  so  relaxed  that 
various  manipulations  can  readily  be  made.  Seizing  the 
shoulder-joint  with  one  hand,  the  clavicle  is  grasped  between 
the  thumb  and  fingers  of  the  other,  and,  while  the  shoulder 
is  alternately  elevated  and  depressed,  carried  forward  and 
backward,  corresponding  counter-movements  with  the  fin- 
gers grasping  the  clavicle  are  made.  Preternatural  mobility 
and  crepitus  will  thus  in  most  cases  become  distinctly  ap- 
parent, and  the  seat  of  fracture  can,  as  a  rule,  be  accurately 


FRACTURES    OF   THE    UPPER    EXTREMITY.  IOI 

located.  If  the  inner  fragment  stands  out  prominently 
beneath  the  integument,  its  tendency  to  obliquity  can  be 
ascertained  by  its  sharpness.  If  the  fracture  is  situated  at 
either  the  sternal  or  the  acromial  extremity,  crepitus  with 
very  slight  or  no  mobility,  and  either  slight  or  no  deformity, 
are  usually  present.  By  the  aid  of  these  various  manipula- 
tions difficulty  will  rarely  be  found  in  making  an  accurate 
diagnosis. 

Treatment. — The  very  large  number  of  appliances  of 
various  sorts  which  are  recommended  and  employed  in  the 
treatment  of  fracture  of  the  clavicle  give  the  best  evidence 
of  the  difficulties  which  are  encountered  in  managing  it  satis- 
factorily. The  principal  indications  are  universally  recog- 
nized, and  almost  every  apparatus  suggested  fulfils  them 
in  the  same  general  line,  though  bv  various  means.  The 
shoulder  droops,  it  must  be  elevated  ;  it  is  drawn  forward, 
it  must  be  thrown  backward  ;  it  is  narrowed,  it  must  be 
restored  to  its  natural  breadth.  Whatever  apparatus  is  used 
is  designed  in  its  own  particular  fashion  to  correct  these 
abnormal  tendencies.  But  the  correction  of  deformity  is 
not  the  only  consideration.  Fixation  after  the  displacement 
has  been  overcome,  at  least  as  perfect  fixation  as  can  be 
obtained,  is  absolutely  essential.  Fixation  depends  not  only 
upon  retaining  the  shoulder-joint  and  upper  extremity  at 
rest,  as  the  patient  stands  before  you,  but  also  upon  so 
controlling  voluntary  muscular  actions  by  the  dressing 
that  he  will  not  immediately  move  the  fragments  unwit- 
tingly. This  he  may  do  in  performing  various  acts  with 
his  sound  arm,  in  lying  down,  turning  in  bed,  or  in  dressing 


102  A    CLINICAL    TREATISE    ON  FRACTURES. 

and  undressing.  Two  very  important  details  in  the  appli- 
cation of  any  dressing  which  tends  to  promote  the  perfect 
fixation  of  the  fragments  are  :  (i)  To  employ  a  dressing 
which  will  both  in  position  and  in  degree  of  tension  remain 
unchanged  between  visits.  (2)  To  employ  a  dressing  that 
will  be  sufficiently  comfortable  to  the  patient  in  all  respects 
to  avoid  his  being  tempted  to  meddle  with  it  with  his  other 
hand.  It  will  at  once  be  seen  that  the  use  of  many  appli- 
ances is  negatived  by  carrying  out  these  two  details  only. 
Slings,  handkerchiefs,  and  bandages,  as  frequently  applied, 
become  so  slack  in  a  few  hours  that  they  accomplish  nothing. 
All  apparatus  made  fast  by  tapes,  buckles,  or  knots  are  to 
be  avoided  in  most  cases,  as  the  patient  readjusts  them  to 
suit  himself ;  no  discretion  must  be  given  him  but  with 
the  full  knowledge  of  the  surgeon.  Many  more  appliances 
will  be  found  undesirable  if  the  matter  of  comfort  is  con- 
sidered. This  observation  can  be  appreciated  by  any  one 
who  has  ever  had  any  injury  about  the  shoulder-joint,  and 
who  has  experienced  the  extreme  discomfort  of  certain 
apparatus.  A  dressing  must  be  applied  which  will  not 
excoriate  any  part  of  the  integument,  will  not  obstruct 
respiration  in  the  recumbent  posture,  and  will  not  confine 
the  arm  and  forearm  in  an  intolerable  position.  A  dressing 
which  will  be  found  almost  invariably  applicable  in  meeting 
these  various  indications,  if  it  is  used  with  careful  atten- 
tion to  every  necessary  detail,  in  subjects  of  both  sexes  and 
all  ages,  is  the  dressing  of  Desault,  perhaps  slightly  modi- 
fied. When  this  is  to  be  applied  there  should  first  be  a 
few  days'   confinement  to  bed,   if  practicable.     The  patient 


FRACTURES    OF   THE    UPPER   EXTREMITY.  IO3 

should  lie  flat  on  his  back  upon  a  rather  hard  mattress 
and  a  low  pillow,  which  position,  if  maintained  con- 
tinuously, will  generally  overcome  the  deformity  com- 
pletely. Desault's  dressing  may  then  be  applied  in  the 
following  manner:  A  large  pad  in  the  axilla,  best  made 
of  oakum,  folded  into  a  piece  of  canton-flannel  or  patent 
lint  in  the  form  of  a  wedge  can  be  perfectly  retained  in 
position  by  the  application  of  the  second  roller  of  Desault. 
Having  placed  two  layers  of  lint  upon  the  injured  shoulder, 
beneath  the  elbow,  and  in  the  sound  axilla,  the  third 
roller  is  applied.  The  forearm  will  then  be  found  to  rest 
against  the  abdomen,  and  contact  of  skin  surfaces  is  pre- 
vented by  the  insertion  of  one  layer  of  lint.  If  the  subject 
is  fleshy,  lint  should  also  be  placed  in  the  fold  at  the  bend 
of  the  elbow.  A  comfortable  sling  padded  at  the  back  of  the 
neck  and  beneath  the  wrist  supports  the  hand,  with  the  fore- 
arm in  a  state  of  right-angled  flexion.  In  applying  the 
third  roller,  the  numerous  turns  across  the  injured  shoulder 
should  be  made  to  intersect  close  enough  to  the  root  of  the 
neck  to  press  upon  the  inner  fragment  if  possible  ;  but  a 
compress  at  this  point  is  seldom  necessary.  Remembering 
that  many  yards  of  roller  bandage  are  carried  around  the 
chest  in  the  application  of  these  two  parts  of  Desault's  dress- 
ing, and  that  each  turn  increases  the  aggregate  constriction 
of  the  chest,  too  much  tension  should  not  be  employed.  In 
order  to  prevent  any  of  the  turns  becoming  disarranged, 
and  also  to  lessen  the  tendency  of  the  roller  bandage  to 
become  slack,  one-inch  straps  of  rubber  adhesive  plaster  two 
yards  long  should  follow  the  turns  of  the  third  roller,  and  be 


104  A    CLINICAL    TREATISE    ON  FRACTURES. 

also  carried  around  the  chest  and  upper  and  lower  parts  of 
the  arm.  By  this  dressing  fixation  as  complete  as  by  any 
other  is  perhaps  obtained ;  and  it  may  be  further  promoted 
by  warning  the  patient  to  allow  his  injured  shoulder  and 
arm  to  hang  as  relaxed  as  possible  ;  certain  it  is,  that  if 
he  is  ignorant  of  the  harm  he  does,  he  may  move  his 
shoulder  at  will  and  disturb  the  fragments,  no  matter  how 
securely  they  are  retained  by  any  dressing. 

The  position  thus  maintained  Sayre,  of  New  York,  accom- 
plished by  an  ingenious  application  of  broad  adhesive  strips. 
The  first  of  these,  which  is  long  enough  to  encircle  the  arm 
and  one-third  more  than  the  circumference  of  the  trunk, 
of  a  breadth  of  three  and  a  half  inches,  is  looped  by  its 
initial  extremity  around  the  middle  of  the  arm.  The  loop 
is  held  secure  by  a  pin,  or,  better,  two  or  three  stitches, 
while  the  free  end  is  carried  transversely  across  the  back, 
around  the  front  of  the  chest,  and  again  to  the  back,  its 
terminal  end  being  fastened  to  that  portion  just  beyond  the 
spine  on  the  sound  side.  This  encircling  strip  surrounds  the 
chest  on  a  level  with  the  middle  of  the  arm  and  retains  the 
arm  somewhat  back  of  the  vertical  line.  The  second  strip, 
long  enough  to  traverse  a  circumference  corresponding  to 
a  plane  from  the  middle  of  the  sound  shoulder  to  the  injured 
elbow,  has  its  initial  extremity  fixed  over  the  sound  scapula, 
whence  it  is  carried  obliquely  downward  across  the  back  to 
the  injured  elbow,  to  which  it  is  made  to  give  a  decided  but 
not  forcible  support,  up  the  chest,  including  in  its  course 
the  forearm  and  hand,  to  the  shoulder  on  the  sound  side 
and  to  the  starting-point,  its  terminal  end  should  be  securely 


FRACTURES    OF   THE    UPPER   EXTREMITY.  105 

attached  to  its  initial  end.     In  order  that  the  point  of  the 
elbow  shall  not  receive  undue  pressure  a  small  hole  is  made 
in  the  plaster  at  a  corresponding  point  to  the  latter,  which, 
with  the  addition  of  a  little  lint  padding,  will  protect  this 
very  sensitive  part  from  excoriation.     Even  a  slight  growth 
of  hair  upon  the  forearm,   or  elsewhere,   should  invariably 
be  removed  with  a  razor  before  the  application  of  this  or 
any  similar  adhesive  plaster  apparatus.     In  order  that  the 
arm-loop   shall    not  disturb  the   circulation  in  the    forearm 
and   hand,   it  should  not  be  made  to  encircle  the  arm  too 
tightly.     Close  attention  should  be  paid  to  the  edges  of  the 
adhesive  plaster  at  all  points  lest  they  excoriate  the  skin. 
The  dressing  of  Desault  should  be  removed  in  two  days, 
and,  after  thorough  bathing  of  the  skin  with  alcohol,  reap- 
plied.    During  this  process  upward  pressure  of  the  elbow 
and  backward  pressure  of  the  shoulder  will  retain  the  frag- 
ments at  the  seat  of  fracture  in  proper  apposition.     After 
this  the  dressing  may  often  be  allowed  to  remain  undisturbed 
for  four  or  five  days  throughout  the  treatment,  but  it  must 
always  be  changed  at  any  time  it   becomes  loose.     Under 
favorable   conditions    the    bone    will    appear   firm    in    three 
weeks ;  but  as  it  is  not  strong,  the  dressing  should  be  con- 
tinued   for   ten   days    after   apparent    union    occurs.     After 
discarding  the  special  dressing  the  arm  may  be  retained  to 
the   chest   and    the   hand   supported  by  a  single   turn  of  a 
bandage  and  a  sling  until  they  can  be  prudently  released. 
Passive    movements  of  the    shoulder-joint   may  usually  be 
begun  in  the  second  week,  and  continued  at  every  dressing 
thereafter. 


CHAPTER    Hi. 
FRACTURES   OF  THE   LOWER   EXTREMITY. 

FRACTURES    OF   THE    FOOT. 

Fractures  of  the  Phalanges. — Usually  fractured  by 
direct  violence — that  is,  by  being  crushed  beneath  some 
heavy  falling  object — the  phalanges  of  the  toes  are  occa- 
sionally fractured  by  force  indirectly  applied  to  their  tips. 
As  with  fractures  of  the  phalanges  of  the  fingers,  the  force 
required  to  break  the  toes  is  so  great  that  the  injured  toe 
is  frequently  the  seat  of  severe  damage  of  the  soft  parts  as 
well  as  of  the  bone.  In  simple  fractures  there  is  seldom 
much  displacement,  though  almost  invariably  considerable 
contusion  of  the  soft  tissue. 

Diagnosis. — By  extension  exerted  upon  the  tip  of  the 
toe,  alternated  with  a  movement  which  thrusts  it  toward 
the  foot,  and  by  rotation  in  various  directions  while  the 
suspected  seat  of  fracture  is  held  between  the  thumb  and 
fingers,  pain  on  pressure,  moderate  preternatural  mobility, 
and  usually  crepitus  can  be  elicited.  Phalangeal  joints  are 
so  frequently  already  distorted  that  little  evidence  can  be 
obtained  from  inspection  of  contour. 

Treatment. — Any  deformity  present  can  usually  be  over- 
come by  manipulation.  The  patient,  if  possible,  should 
be  put  to  bed  and  an  evaporating  lotion  applied  to  the 
injured  toes.     To  retain  the  fracture  in  a  state  of  fixation, 

106 


FRACTURES    OF   THE   LOWER   EXTREMITY.  \OJ 

a  cardboard  splint  cut  to  conform  to  the  margin  of  the  foot, 
very  much  in  the  shape  of  the  sole  of  a  shoe,  should  be 
applied.  Three  or  four  layers  of  patent  lint  furnish  suf- 
ficient padding,  and  the  splint  is  applied  in  a  macerated 
condition  and  retained  by  a  spica  bandage  of  the  foot.  At 
the  end  of  one  week  the  patient  may  be  allowed  out  of  bed, 
and  the  splint  should  be  continued  for  three  weeks,  after 
which  no  retaining  dressing  is  required  unless  the  fracture 
be  of  one  of  the  phalanges  of  the  great  toe,  which,  as  the 
latter  takes  a  more  important  part  in  the  function  of  the 
foot,  should  be  kept  at  rest  for  four  and  a  half  weeks. 

Fractures  of  the  Metatarsal  Bones. — Fracture  of  the 
metatarsal  bones  is  much  more  likely  to  be  caused  by  direct 
than  by  indirect  violence ;  and  among  the  various  ways  in 
which  the  force  may  be  applied,  the  falling  of  heavy  objects 
upon  the  foot  is  much  the  most  frequent. 

Diagnosis. — The  detection  of  fracture  of  the  first  and 
fifth  metatarsal  bones  is  usually  easy;  of  the  intervening 
ones,  difficult,  as  the  dense  tissues  constituting  the  ten- 
dinous and  ligamentous  structures  of  the  foot  are  made 
extremely  tense  by  the  contusion  accompanying  the  fract- 
ure. It  is  often  impossible,  particularly  without  the  use  of 
an  anaesthetic,  to  obtain  positive  evidence  of  fracture  of  a 
metatarsal  bone  ;  and  it  is  not  uncommon  that,  a  fracture 
of  one  metatarsal  bone  having  been  demonstrated,  a  fract- 
ure in  one  or  more  of  the  others  is  overlooked.  Again,  the 
nearer  the  fracture  is  to  the  base  of  the  bone  the  more  diffi- 
cult it  is  to  eliminate  the  mobility  of  the  tarsometatarsal 
articulation   and   to  obtain   crepitus.      These   conditions  are 


io8 


A    CLINICAL    TREATISE    ON  FRACTURES. 


shown  in  Fig.  54,  illustrating  transverse  fracture  at  the  base 
of  the  second,  oblique  fracture  of  the  third,  and  transverse 
fracture  of  the  fourth  metatarsal  bone.  By  alternately  lifting 
and  depressing  the  head  of  each  metatarsal  bone  in  turn, 
while   a  counter-movement   is    made  with    the    thumb    and 


Fig.  54. 


Skiagraph  of  fracture  of  three  metatarsal  bones. 

fingers  of  the  other  hand  at  the  middle  third  of  the  shaft, 
preternatural  mobility  and  crepitus  may  be  detected,  but 
overlapping  sufficient  to  produce  deformity  apparent  through 
the  integument  is  uncommon.  Pain  as  a  diagnostic  symp- 
tom  is  of  little  value,  as  a  contusion  of  the  foot  will  fre- 


FRACTURES   OF   THE   LOWER   EXTREMITY.  IO9 

quently  cause  as  much   pain  and  tenderness  on  pressure  as 
a  fracture  of  a  metatarsal  bone. 

Treatment. — As  there  is  rarely  any  deformity  requiring 
correction,  efforts  should  be  directed  primarily  to  reducing 
the  tension.  This  may  be  best  accomplished  by  elevation 
and  the  application  of  evaporating  lotions.  During  the  first 
fortnight  the  patient  had  far  better  remain  in  bed ;  and 
while  there,  there  is  little  tendency  of  the  fragments  either 
to  become  displaced  or  to  be  movable  ;  the  application  of  a 

FIG.  55- 


Skiagraph  of  fracture  through  the  middle  of  the  os  calcis. 

plantar  cardboard  splint,  retained  with  a  spica  bandage, 
promotes  the  patient's  comfort  by  giving  him  confidence  to 
change  the  position  of  his  foot  without  risk  of  doing  harm. 
Where  the  swelling  is  not  excessive,  or  subsides  in  a  few 
hours,  a  plaster-of-Paris  dressing,  including  the  foot  from  the 
tips  of  the  toes  to  the  ankle,  furnishes  an  excellent  method 
for  the  treatment  of  this  fracture. 

Fractures  of  the  Tarsus. — Considered  as  a  whole,  sim- 
ple   fracture    of    the    tarsus   is   more    common   than   simple 


no 


A    CLINICAL    TREATISE    ON  FRACTURES. 


Fig.  56. 


fracture  of  the  carpus.  Simple  fractures  of  the  smaller 
bones — the  scaphoid,  cuboid,  internal,  middle,  and  external 
cuneiform — are  very  rare.  Fracture  of  the  astragalus  is  also 
rare,  the  os  calcis  being  the  one  bone  of  the  tarsus  which 
is  most  liable  to  yield  through  the  action  and  degree  of 
forces  applied  in  such  a  manner  as  to  cause  a  simple  fract- 
ure. Of  these,  falling  or  jumping  from  a  height  and  light- 
ing on  the  feet  is  the  most  usual  cause  of  fracture.  Fracture 
may  result  from  violent  contraction  of  the  tendo  Achillis, 

when  there  is  usually  merely 
a  tearing  off  of  a  thin  plate 
of  bone  immediately  under- 
lying the  insertion  of  the 
tendon.  The  plane  of  fract- 
ure involving  the  os  calcis 
is  apt  to  be  vertical  and, 
approximately,  through  the 
middle  of  the  bone,  as  shown 
in  Fig.  55.  More  rarely  the 
line  of  fracture  is  anterior 
to  this,  as  shown  in  Fig.  56.  The  fibrous  envelope  of  this 
bone  is  so  dense  and  complete  that  little  deformity  results. 
The  sustentaculum  tali  is  rarely  fractured  ;  but  occasionally 
a  sudden  and  forcible  inversion  of  the  foot  breaks  it  off. 
Fracture  of  the  astragalus,  very  rare  as  a  simple  injury,  may 
be  caused  by  a  fall  from  a  height  upon  the  foot.  Fig.  57 
represents  a  fracture  through  the  neck  of  the  bone,  the 
diagnosis  of  which  was  definitely  made  before  the  skiagraph 
was  taken. 


Fracture  of  the   os  calcis. 


FRACTURES   OF  THE  LOWER  EXTREMITY. 


II  I 


Diagnosis  of  Fractures  of  the  Tarsus. — Os  Calcis. 
— If  the  fracture  involve  the  body  of  the  bone  behind  the 
insertion  of  the  lateral  ligaments,  preternatural  mobility  may 
be  detected  by  swaying  the  heel  from  side  to  side,  while 
the  foot  is  grasped  firmly;  and  during  the  performance  of 

Fig.  57. 


Skiagraph  of  fracture  of  the  neck  of  the  astragalus. 

these  movements  crepitus  may  be  elicited.  If  in  front  of  the 
insertion  of  the  lateral  ligaments,  the  signs  of  fracture  are 
much  more  difficult  to  obtain;  indeed,  it  is  often  impossible 
to  detect  mobility  or  crepitus  without  the  exercise  of  a 
degree  of  force  which  is  perhaps  unjustifiable  unless  the 
patient  is  anaesthetized.  Should  the  fracture  involve  the 
posterior  extremity  of  the  bone,  the  surface  for  insertion 
of  the  tendo  Achillis  having  been  dragged  off  by  the  latter, 
there  will  be  observed  complete  inability  to  extend  the  foot, 


112  A    CLINICAL    TREATISE    ON  FRACTURES. 

the  calf  will  be  completely  relaxed,  and  the  contour  of  the 
ankle  will  be  so  altered  that  a  depression  will  be  observed 
upon  its  posterior  aspect,  instead  of  the  sharply  defined 
prominence  of  the  tendon.  The  symptoms  observed  in  the 
rare  instances  in  which  the  sustentaculum  tali  has  been 
torn  off  are  eversion  of  the  foot  with  complete  inability  to 
invert  it,  the  foot  thus  assuming  the  position  of  valgus ; 
and  shortening  of  the  heel  by  slight  forward  displacement 
of  the  os  calcis.  When  these  conditions  are  observed  in 
the  absence  of  a  fracture  of  the  lower  end  of  the  fibula, 
producing  Pott's  fracture  deformity,  or  laceration  of  the 
internal  lateral  ligament  of  the  ankle-joint,  fracture  of  this 
process  may  be  suspected. 

Astragalus. — As  already  stated,  fracture  of  this  bone  is 
so  rare  that  when  it  occurs  it  is  likely  to  escape  observation 
if  the  fracture  involves  any  other  part  than  the  neck.  The 
case,  a  skiagraph  of  which  is  reproduced  in  Fig.  57,  occurred 
in  a  very  large,  heavy  man  who  had  fallen  a  considerable 
distance.  Pain  just  in  front  of  the  ankle-joint  suggested 
the  examination  of  the  astragalus,  which  revealed  crepitus, 
and  slight  preternatural  mobility  at  a  point  corresponding 
to  its  neck.      But  there  was  no  deformity. 

Treatment  of  Fractures  of  the  Tarsus. — Os  Calcis. 
— If  the  os  calcis  is  fractured  but  not  displaced,  or  if  the 
displacement  is  so  slight  that  it  can  be  detected  only  by  a 
skiagraph,  rest  for  a  period  of  a  fortnight  (after  which  the 
swelling  will  usually  have  receded)  is  the  most  important 
part  of  the  treatment.  During  this  time  a  fracture-box  may 
well  be  employed  to  keep  the  foot  at  rest.     At  the  end  of 


FRACTURES   OF   THE   LOWER   EXTREMITY.  I  I  3 

two  weeks  a  plaster-of- Paris  bandage,  extending  from  the 
tips  of  the  toes  to  a  point  just  above  the  ankle-joint,  will 
give  the  patient  sufficient  support  to  enable  him  to  get  out 
of  bed  and  sit  in  a  chair  with  the  leg  elevated.  After  three 
weeks  he  may  safely  walk  on  crutches,  but  should  not  put 
weight  upon  his  foot  until  the  plaster-of-Paris  dressing  has 
been  cut  and  removed,  which  may  be  done  at  the  end  of 
four  and  a  half  or  five  weeks. 

As  the  deformity  resulting  from  fracture  through  any 
portion  of  the  posterior  part  of  the  bone  consists  in  either 
tilting  or  complete  separation  of  the  posterior  fragment 
through  the  action  of  the  gastrocnemius  and  soleus  muscles, 
the  greatest  relaxation  of  these  must  be  obtained  in  order 
more  readily  to  bring  the  posterior  fragment  forward.  Re- 
tention of  the  foot  in  a  state  of  complete  extension  still 
further  favors  coaptation,  which  is  best  obtained,  after  an 
anterior  obtuse-angled  splint  has  been  placed  in  position, 
bv  the  application  of  a  basket-like  arrangement  of  rubber 
adhesive  strips  made  to  envelop  the  calf  completely,  each 
strip  converging  at  the  heel  and  anchored  on  the  sole  of 
the  foot.  Should  these  measures  fail  to  secure  approxima- 
tion sufficient  to  warrant  the  assumption  that  good  union 
will  occur,  it  is  quite  proper,  provided  the  surgical  require- 
ments for  operation  are  complete,  to  cut  down  and  suture 
the  fragments  with  silkworm-gut  or  silver  wire. 

Astragalus. — As  there  is  no  deformity  after  fracture  of 
the  astragalus,  the  treatment  is  very  simple,  and  consists 
of  rest.  The  limb  is  therefore  conveniently  placed  in  a 
fracture-box  for  a  few  days  until  any  swelling  has  subsided, 


114  A    CLINICAL    TREATISE    ON  FRACTURES. 

when  a  plaster-of-Paris  dressing  is  applied  and  retained  for 
four  weeks.  At  the  end  of  this  time  gentle  use  of  the 
extremity  may  be  begun. 

FRACTURES   OF  THE  LEG. 

Fractures  of  the  leg  include  fracture  of  (i)  the  tibia,  of 
(2)  the  fibula,  or  of  (3)  both  these  bones. 

(1)  Fractures  of  the  Tibia. — Fractures  of  the  tibia  may 
be  conveniently  considered  under  (a)  the  lower  extremity 
and  (b)   the  shaft. 

Fractures  of  the  upper  extremity  not  involving  the  knee- 
joint  possess  so  few  characteristics  not  common  to  fract- 
ures elsewhere  in  the  shaft  that  they  need  not  be  separately 
described. 

(a)  Fractures  of  the  Lower  Extremity  of  the  Tibia 
{Fractures  of  the  Internal  Malleolus). — The  internal  malle- 
olus may  be  broken  at  a  point  so  low  down  that  merely  its 
tip,  remaining  attached  to  the  internal  lateral  ligament  of 
the  ankle-joint,  is  broken  off ;  or  it  may  be  fractured  at  its 
base,  so  that  the  lower  fragment  consists  of  the  entire 
process.  Little  deformity  may  result,  though  the  tendency 
is  to  eversion  of  the  foot.  The  line  of  fracture  may  extend 
through  the  lower  extremity  of  the  bone  just  above  the 
articular  surfaces,  or  its  plane  may  be  slightly  oblique  in  any 
direction  ;  if  so,  the  deformity  resulting  is  determined  in  its 
direction  by  the  inclination  of  the  oblique  plane,  though 
any  overlapping  present  is  caused  by  muscular  contraction. 

(b)  Fractures  of  the  Shaft  of  the  Tibia. — Fractures  of 
the  shaft  of  the  tibia  incline  to  be  transverse  if  the  fracture 


FRACTURES    OF   THE   LOWER  EXTREMITY. 


115 


has  been  caused  by  force  directly  applied  ;  and  incline  to  be 
oblique  if  the  force  producing  the  fracture  has  been  indirect 
(Fig.  58).  Fractures  of  the  upper  third  incline  more  to  be 
transverse,  while  fractures  of  the  middle  and  lower  thirds 
are  more  frequently  oblique.     The  extent  of  deformity  after 


fig.  58. 


Skiagraph  of  oblique  fracture  of  the  shaft  of  the  tibia. 


fractures  of  the  tibia  is  usually  in  direct  proportion  to  the 
obliquity  of  the  fracture  ;  and  while  this  deformity  is 
clearly  influenced  by  the  direction  of  the  plane  of  fracture, 
it  is  most  commonly  observed  to  result  in  anterior  bowing 
with  prominence  of  the  upper  fragment.  If  the  plane  of 
fracture  assumes  a  somewhat  spiral  form,  rotation  inward  or 


n6 


A    CLINICAL    TREATISE    ON  FRACTURES. 


outward  in  the  direction  of  this  spiral  results,  constituting 
what  has  been  described  as  corkscrew  fracture  (Fig.  59). 
The  anterior  bowing  depends  not  only  upon  the  predomi- 
nance in  strength  of  the  posterior  group  of  muscles,  but 
probably  also  to  some  extent  upon  the  weight  of  the  foot. 
This  latter,  though  an  unimportant  element  in  the  produc- 
tion of  the  original  deformity,  should  not  be  lost  sight  of  in 


Fig.  59. 


Fig.  60. 


Skiagraph   of  corkscrew  fracture    of  the         Skiagraph  of  green-stick  fracture  of  the 
shaft   of   the    tibia.  tibia. 


treatment.  Green-stick  fracture  of  the  tibia  is  rare,  but 
Fig.  60  represents  such  a  fracture  which  apparently  had 
immediately  sprung  back  into  position. 

Diagnosis. — The  diagnosis  of  fracture  of  either  the 
lower  extremity  of  the  tibia  or  of  its  shaft  is  seldom  diffi- 
cult. At  the  lower  extremity,  while  there  may  be  no  de- 
formity, preternatural  mobility  and  crepitus  can  usually  be 


FRACTURES    OF   THE   LOWER    EXTREMITY.  WJ 

readily  elicited  by  forcibly  inverting  and  everting  the  foot, 
while  the  fingers  of  the  left  hand  are  placed  over  the  lower 
portion  of  the  tibia.  If  no  deformity  is  apparent,  and  none 
can  be  produced  by  manipulation,  and  no  undue  mobility 
or  crepitus  can  be  detected,  important  data  bearing  upon 
the  subsequent  treatment  have  been  secured.  If  the  fract- 
ure is  situated  in  the  shaft,  the  deformity,  preternatural 
mobility,  and  crepitus  are  in  the  vast  majority  of  cases  so 
distinctly  apparent  that  the  diagnosis  is  rendered  entirely 
simple. 

Fractures  of  the  Upper  Extremity  of  the  Tibia. — As 
has  been  stated,  fractures  of  the  upper  extremity  of  the 
tibia  possess  few  characteristics  not  common  to  fractures 
situated  elsewhere  in  the  bone.  Fractures  just  below  the 
tubercle  are  very  liable  to  be  transverse.  In  their  diagnosis, 
therefore,  the  fact  that  there  is  seldom  any  overlapping 
must  be  borne  in  mind.  Preternatural  mobility  and  crepitus 
are  readily  detected,  but  any  deformity  present  will  be  found 
to  be  due,  not  to  overlapping,  but  to  rotation  of  the  lower 
fragment,  either  external  or  internal,  or  to  deflection  in  any 
direction  of  its  long  axis  away  from  that  of  the  upper  frag- 
ment. Fractures  of  the  head  of  the  tibia,  involving  the 
joint,  extend  from  somewhere  about  the  middle  of  the  artic- 
ular surface  to  the  inner  aspect  of  the  shaft  or  to  its  outer 
aspect.  If,  therefore,  the  broken  fragment  includes  the  inner 
portion  of  the  articular  surface,  a  deformity  resembling  genu 
varum  is  induced  ;  and  in  the  same  manner,  if  the  broken 
fragment  involves  the  outer  portion  of  the  articular  surface, 
the    condition   of  artificial    genu   valgum   will    probably   be 


Il8  A    CLINICAL    TREATISE    OX  FRACTURES. 

produced.  These  signs,  however,  are  not  sufficiently  charac- 
teristic of  fracture  of  the  head  of  the  tibia,  nor  are  they  so 
generally  present  as  to  be  regarded  as  reliable.  A  more 
searching  examination  frequently  being  necessary,  an  anaes- 
thetic should,   if  possible,   be  used,   as  fractures   about    the 

Fig.  6i. 


Skiagraph  of  comminuted  fracture  of  the  head  of  the  tibia,  with  accompanying 
fracture  of  the  fibula. 

knee-joint  are  extremely  painful.  Fig.  61  shows  a  comminuted 
fracture  of  the  head  of  the  tibia,  the  head  being  separated 
from  the  shaft  and  itself  divided  into  two  fragments.  The 
skiagraph  also  shows  fracture  of  the  head  of  the  fibula. 

Fractures  of  the  Fibula. — Fractures  of  the  fibula,  while 
they  may  occur  at  any  point  in  the  shaft  or  at  either  ex- 
tremity, will  be  described  in  the  order  of  their  importance. 
Those  occurring  at  the  lower  portion  of  the  shaft,  at  a  point 
between  the  junction  of  the  middle  and  lower  thirds  and  the 
articular,  or  malleolar  extremity,  will  first  be  considered. 
Because  of  certain  peculiarities  possessed  by  it,  which  were 


FRACTURES    OF   THE   LOWER   EXTREMITY.  I  1 9 

first  pointed  out  by  Pott,  fracture  at  this  point  has  since 
been  known  as  Pott's  fracture;  and  while  not  invariably 
causing  deformity,  it  is  very  liable  to  do  so.  The  deformity 
when  marked  can  hardly  be  overlooked,  but  it  is  often  so 
slight  that  it  may  readily  escape  detection.  Particularly 
is  this  true  when  no  weight  is  borue  by  the  limb.  Fig. 
62  illustrates  this  condition.     The  photograph,  of  which  it 

Fig.  62. 


Pott's  fracture  of  the  fibula,  with  slight  deformity. 

is  a  reproduction,  was  of  a  recent  fracture  accompanied  by 
very  slight  deformity,  which  could,  however,  be  easily 
increased  by  putting  weight  upon  the  limb.  In  such  cases 
it  is  very  important  to  detect  the  slightest  tendency  to 
deformity  at  the  first  examination.  After  Pott's  fracture, 
the  continuity  of  the  shaft  of  the  fibula  being  lost,  the 
fragments  show  a  tendency  to  cant  inward.  The  external 
malleolus,  which  forms  the  outer  wall  for  the  ankle-mortise, 
is    thereby  deflected    laterally  and  permits  the    trochlea  of 


120  A    CLINICAL    TREATISE    OX  FRACTURES. 

the  astragalus  to  follow  it.  This  increased  latitude  of 
movement  allows  of  eversion  of  the  foot  and  a  condition 
of  artificial  talipes  valgus  is  induced.  The  loss  of  func- 
tion resulting  from  failure  to  overcome  the  tendency  to  this 
deformity  depends  partly  upon  the  diminished  firmness  of 
the  ankle-mortise,  and  partly  upon  the  axis  of  weight 
being  directed  abnormally  to  the  inner  side  of  the  foot. 
This  latter  defect  stretches   the  internal  lateral  ligament  of 

Fig.  63. 


Skiagraph  of  oblique  fracture  in  the  lower  third  of  the  shaft  of  the  fibula. 

the  ankle-joint,  breaks  down  the  arch  of  the  foot,  and  causes 
a  weakness  which  is  progressive.  Both  of  these  conditions 
tend  to  force  the  astragalus  still  further  outward  against 
the  slanting  wall  of  the  external  malleolus,  should  the 
deformitv  not  have  been  wholly  corrected  or  should  the 
patient  be  put  upon  his  feet  before  union  is  entirely  firm. 
Fractures  of  the  external  malleolus,  whether  transverse  or, 
as  shown   in   Fig.    63,    oblique,   if  they   are  so  situated  that 


FRACTURES   OF   THE   LOWER   EXTREMITY.  121 

no  latitude  of  movement  of  the  astragalus  is  allowed  and 
the  ligamentous  attachments  with  both  tibia  and  tarsus 
have  not  been  disturbed,  will  frequently  be  found  to  exist 
without  deformity.  The  fibula  taking  no  part,  strictly 
speaking,  in  the  support  of  the  body,  its  fracture  above  this 
point  does  not  necessarily  even  interfere  with  locomotion, 
seldom  produces  much  deformity,  and  can  therefore  be 
properly  regarded  as  among  the  least  serious  of  fractures 
of  the  leg. 

Diagnosis. — Diagnosis  of  fracture  of  the  upper  portion 
of  the  shaft  of  the  fibula  is  often  difficult  to  establish  ;  the 
pain  present  may  well  depend  upon  contusion  of  the  soft 
parts,  if  the  fracture  has  been  induced  by  direct  violence, 
as  by  the  passage  over  it  of  a  light  wagon-wheel. 
Should  the  seat  of  fracture  be  situated  between  the  junc- 
tion of  the  lower  with  the  middle  thirds  and  the  upper 
extremity  of  the  bone,  preternatural  mobility,  in  thin  sub- 
jects, and  possibly  crepitus  may  at  times  be  produced,  but 
there  is  seldom  any  deformity.  If  the  leg  just  above  the 
ankle  is  forcibly  pressed  between  the  thumb  and  fingers  or 
grasped  between  the  two  hands,  pain  is  often  complained 
of  at  a  point  up  the  leg,  remote  from  pressure.  Such  pain  is 
strongly  indicative  of  the  existence  of  fracture,  and  careful 
palpation  at  this  point  will  often  reveal  slight  preternat- 
ural mobility.  The  diagnosis  of  fracture  of  the  lower  third 
of  the  bone  is  usually  simple,  and  fortunately  so,  for  its  ex- 
istence at  this  point  is  often  more  serious.  Alteration  of 
contour  just  above  the  ankle,  increased  concavity  of  the  outer 
line  of  the   limb,   slight   or   marked    eversion   of  the   foot, 


122  A    CLINICAL    TREATISE    ON  FRACTURES. 

greater  or  less  prominence  of  the  internal  malleolus — all 
point  to  fracture  of  the  lower  third  of  the  fibula.  Touching 
the  bone  at  this  point  with  the  thumb  and  fingers  while 
the  foot  is  firmly  grasped  with  the  other  hand,  forward  and 
backward  swaying  of  the  foot,  alternated  with  its  eversion 
and  inversion,  will  usually  reveal  crepitus  and  preternatural 
mobility  clearly  enough  to  indicate  not  only  the  presence 
of  fracture,  but  also  to  localize  its  seat  with  sufficient 
accuracy.  Should  the  line  of  fracture  extend  through  the 
external  malleolus  in  such  a  direction  that  only  a  portion 
of  the  articular  surface  of  the  bone  is  involved,  and  there  is 
no  separation  of  the  fragments  to  cause  deformity  and  no 
tearing  of  ligaments  to  increase  the  mobility  of  the  ankle- 
joint  in  any  direction,  the  presence  of  fracture  may  be  dif- 
ficult to  determine.  In  such  cases,  however,  the  external 
malleolus,  seized  with  the  tips  of  the  fingers  and  thumb, 
will  be  found  to  be  slightly  movable,  and  perhaps  to  yield 
indistinct  crepitus.  The  pain  present  under  these  circum- 
stances, being  in  all  respects  the  pain  of  a  severe  sprain  of 
the  ankle,   is  valueless  as  a  diagnostic  sign. 

Fractures  of  Both  Bones. — Fractures  of  both  bones  of 
the  leg  possess  characteristics  in  common  with  fractures 
of  the  tibia  or  fibula  alone  and  other  peculiarities  separate 
and  distinct  from  those.  Fracture  of  the  tibia  at  one  point, 
and  of  the  fibula  at  a  point  remote  from  it  may  cause  a 
double  set  of  symptoms.  Thus,  fracture  of  the  upper  third 
of  the  tibia  and  Pott's  fracture  of  the  fibula  will  present  all 
the  symptoms  of  both  of  these  injuries.  On  the  other 
hand,    if    the    two  bones    are    broken    at     points    approxi- 


'■., 


FRACTURES    OF   THE   LOWER   EXTREMITY.  1 23 

mately  similar,  the  characteristic  symptoms  of  fracture  of 
the  tibia,  the  overlapping,  the  bowing,  the  preternatural 
mobility  will  all  be  greatly  exaggerated  by  fig.  64. 

the  fracture  of  the  fibula.  And  finally  the  » r 
symptoms  of  Pott's  fracture  of  the  fibula, 
the  loss  of  natural  contour,  the  eversion  of 
the  foot,  the  prominence  of  the  lower  ex- 
tremity of  the  tibia  will  all  be  greatly  accen- 
tuated by  a  fracture  of  the  lower  extremity 
of  the  tibia,  or  by  its  luxation  inward. 
Comminuted  fractures,  as  illustrated  in 
Fig.  64,  are  also  more  commonly  observed. 
The  conditions  present,  therefore,  in 
fractures  of  both  bones  of  the  leg  may  not 
only  combine    those   belonging    to   fracture 

of  either  bone,  but  also  have  added  to  them 

.  .  .  ......  .,  /^S, 


■ 


others  which  serve  materially  to  increase  the 

.  Comminuted      fract- 

gravity   of    the   1111  ury.       There    is    greater 

*  J  J       J  °  ure    of    the    tibia 

liability  of  damage  to  the  integument  and  and  fibula. 
perhaps  to  the  muscles  and  bloodvessels  because  the 
force  required  to  break  both  bones  is  greater  than  that 
required  to  break  one,  and  because,  neither  bone  deriving 
any  support  from  its  fellow,  the  fractured  fragments  are  free 
to  be  thrust  in  all  directions.  For  the  same  reasons,  over- 
lapping, bowing,  rotation  may  all  be  more  marked,  than 
in  fracture  of  one  bone.  Reduction  is  often  facilitated  by 
the  complete  mobility  at  the  seat  of  fracture,  but  perfect 
fixation  in  true  position  is  rendered  more  difficult.  On  this 
account,  the  liability  to  union  with  deformity,  or  to  ununited 


124 


A    CLINICAL    TREATISE    ON  FRACTURES. 


fracture,  is  increased.  Union  of  the  two  bones  with  one 
another  is  also  liable  to  occur  during  repair,  if  the  fract- 
ures are  at  the  same  point.  Such  a  condition,  by  destroying 
the  natural  elasticity  between  the  bones,  may  perhaps  pre- 
dispose to  subsequent  fracture  (Figs.  65  and  66). 


Fig.  65. 


Fig.  66. 


Co-union  after  fracture  of  tibia  and  fibula.  Fracture  of  tibia  after  co-union  of  bones. 

Treatment  of  Fractures  of  the  Leg. — The  manage- 
ment of  fractures  of  the  leg,  whether  involving  the  tibia 
alone,  the  fibula  alone,  or  both  of  these  bones,  may  well  be 
considered  from  a  general  point  of  view;  because  modifica- 
tions of  the  treatment  usually  applicable  to  all,  made  neces- 


FRACTURES    OF   THE    LOWER    EXTREMITY.  1 25 

sary  by  the  peculiarities  of  any  particular  fracture,  are  in 
most  instances  modifications  of  detail  only.  The  indications 
to  be  met  are  the  retention  of  the  broken  fragments,  after 
being  brought  into  as  perfect  apposition  as  possible,  in  a 
state  of  absolute  fixation,  and  its  continuance  throughout 
the  treatment.  Among  the  causes  for  impairment  of  func- 
tion resulting  from  fractures  of  the  leg,  delayed  union  and 
ununited  fracture  are  not  to  be  lost  sight  of.  They  result 
more  frequently  after  fracture  high  up,  than  fracture  low 
down;  and  as  the  former  is  more  liable  to  be  imperfectly 
controlled  by  the  dressing  than  the  latter,  I  believe  that  in 
most  cases  in  which,  without  other  assignable  cause,  the 
fragments  fail  to  unite,  fixation  will  be  found  to  have  been 
incomplete. 

A  fracture-box,  or  other  splint,  which  extends  only  a 
short  distance  above  the  seat  of  fracture,  controls  only  the 
lower  fragment;  it  does  not  control  the  upper  fragment. 
With  such  a  fracture-box,  the  foot  and  lower  fragment  are 
held  firm,  while  the  upper  fragment  follows  the  various 
movements  of  the  patient  whenever  he  changes  his  position 
in  bed.  If  the  fracture  is  above  the  middle  of  the  shaft, 
it  is  doubtful  whether  complete  control  of  the  upper  frag- 
ment can  ever  be  obtained  by  a  fracture-box  or  by  any 
dressing  which  does  not  extend  at  least  as  far  as  the  middle 
of  the  thigh.  Measurable  control  of  lateral  movements  may 
be  secured;  but  control  of  rotary  movements,  caused  by  turn- 
ing of  the  pelvis  in  either  direction,  cannot  be  had;  and 
such  movements  are  perhaps  the  most  insidious  ones  to  be 
dealt  with.       Anterior  bowing,    as   mentioned   above,    being 


126  A    CLIXICAL    TREATISE    OX  FRACTURES. 

the    most    common    tendency  for   the  deformity  to  assume, 
should  be  entirely  overcome  and  even  slightly  overcorrected 
before  the  dressing  is  applied,   as  it  is  extremely  inclined 
to  reassert  itself  through  sagging  of  the  foot.     Rotation  of 
the  lower  fragment  inward  or  outward  should  also  be  care- 
fully avoided,  as  subsequent  in-toeing  or  out-toeing  of  the 
foot  may  produce  more  serious  permanent  interference  with 
function  than  a  slight  bowing  or  slight  overlapping.     There 
is  a  prevalent  tendency  to  apply  all  fixed  dressings  to  the 
lower  extremity  with  the  foot  more  or  less  extended.     This 
is  to  be  particularly  avoided,  as  any  rigidity  at  the  ankle- 
joint  remaining  after  the  treatment  is  discontinued  leaves 
the  foot  in  a  position  of  talipes  equinus.     This  may  often 
require  the  use  of  an  anaesthetic  and  the  exercise  of  consid- 
erable   force   to    correct.     The    single    and    simple   dressing 
employed    almost    universally    is    that    of    plaster-of-Paris. 
Excessive   swelling  of   the   limb,    however,    at  the  seat  of 
fracture,  accompanied  by  phlyctense  and   blebs,   contraindi- 
cates  the  application   of  a  plaster-of-Paris  dressing,  for  not 
only  does  such   a  dressing  mask  subsequent  sloughing  of 
the  integument  or  suppuration  of  the  cellular  tissue  which 
may  occur,  but    the    amount  of  soft    padding   which    it    is 
necessary  to  apply  beneath  the  plaster-of-Paris  in  such  cases 
also  prevents  the  latter  from  giving  the  required  support  to 
the  broken  fragments.    If  applied  immediately  after  the  injury, 
over- tension  from  swelling  must  be  guarded  against,  either  by 
the  application  with  the  initial  flannel  bandage  of  a  certain 
amount  of  a  soft,  yielding  padding,  by  applying  the  plaster- 
of-Paris   bandage   rather   loosely,    or   by   cutting   a   vertical 


FRACTURES    OF   THE   LOWER   EXTREMITY.  \2J 

incision  through  the  dressing  as  soon  as  the  plaster-of-Paris 
has  set.  These  precautions  are  usually  unnecessary  if  the 
application  of  the  dressing  is  delayed  long  enough  for  the 
swelling  to  have  receded.  There  is  no  objection  to  this 
delay,  and  it  is,  therefore,  usually  desirable,  provided  that 
the  limb  meanwhile  is  made  comfortable  and  properly  con- 
fined in  a  fracture-box  extending  far  enough  above  the  seat 
of  fracture  to  give  fair  control  of  the  upper  fragment ;  for  a 
dressing  applied  after  the  limb  has  nearly  resumed  its  normal 
dimensions  fits  better  throughout  the  treatment.  An  excep- 
tion to  this  rule  worthy  of  mention  is  when  a  patient  is 
threatened  with  an  attack  of  delirium  tremens.  Then  a  very 
heavy,  strong,  fixed  dressing  should  be  applied  immediately, 
as  the  best  safeguard  against  the  damage  liable  to  be  done,  if 
the  patient,  losing  control  of  himself,  thrashes  his  leg  about. 
Tenotomy  of  the  tendo  Achillis  may  be  indicated  to  prevent 
serious  damage  at  the  seat  of  fracture  from  muscular  con- 
traction in  cases  of  very  active  delirium  tremens,  but  seldom 
as  a  procedure  required  to  overcome  displacement.  A  plas- 
ter-of-Paris dressing  may  usually  be  applied  without  the 
employment  of  an  anaesthetic.  If,  however,  deformity  exists 
which  cannot  be  reduced,  or  if,  after  reduction,  it  cannot 
be  kept  reduced  during  the  application  of  the  dressing,  it  is 
better  to  get  thorough  control  of  the  limb  and  complete 
muscular  relaxation  by  anaesthesia.  The  limb  should  be 
perfectly  under  control  while  the  plaster-of-Paris  bandage  is 
being  applied.  Three  trained  assistants  are  required  :  one 
to  support  the  thigh,  another  to  support  the  leg  and  foot, 
and  the  third  to  assist  the  surgeon  with  the  plaster  bandages 


128  A    CLINICAL    TREATISE    OX  FRACTURES. 

and  the  manipulation  of  the  plaster-of-Paris.  If  so  much 
help  is  not  at  command,  some  device  which  will  support  the 
limb  in  proper  position  may  be  used.  One  can  be  quickly 
extemporized  on  any  bedstead.  Two  uprights  (clothes-props) 
attached  vertically  to  the  head  and  foot  of  the  bed  are 
joined  at  the  top  by  a  third  horizontal  piece  resting  upon 
them,  and  held  fast  by  wire  nails.  The  patient  rests  in  bed 
m  such  a  position  that  his  fractured  leg  is  directly  beneath 
the  horizontal  bar.  The  fractured  leg  is  then  placed  upon 
two  pillows  which  will  elevate  it  about  five  inches  from  the 
bed,  which  involves  slight  flexion  of  the  knee-joint.  Rubber 
adhesive  suspension  straps  are  then  applied  to  the  middle 
of  the  thigh  and  to  the  foot.  These  are  turned  upon  them- 
selves so  that  they  shall  have  a  loop  above,  through  which 
a  cord  can  be  passed,  which,  being  drawn  taut,  is  made 
fast  to  the  horizontal  bar.  On  removing  the  pillows  the 
limb  may  be  found  sufficiently  supported.  If  a  third  point 
of  support  is  needed,  it  should  be  in  the  form  of  a  prop  from 
beneath  the  limb  to  the  bed.  For  this  purpose  a  slender 
stick,  like  a  lead-pencil,  cut  to  the  proper  length  and  padded 
with  a  little  knob  of  muslin,  is  placed  at  the  desired  point, 
there  to  remain  until  the  application  of  the  plaster-of-Paris 
bandage  is  completed.  By  a  little  experimental  slackening 
and  tightening  of  the  suspending  cords  the  limb  will  finally 
be  suspended  in  very  correct  position  without  any  manual 
aid.  Gentle  pressure  with  a  finger  or  between  the  fingers 
and  thumb  at  some  point  where  slight  deformity  persists 
may  at  times  be  necessary  to  perfect  the  modelling  process. 
In  order    to  insure  perfect  fixation   of  the  fragments  in 


FRACTURES   OF   THE   LOWER   EXTREMITY.  1 29 

various  fractures,  a  rule  always  to  be  observed  is  to  control 
the  knee-joint  by  carrying  trie  dressing  from  the  toes  to  the 
junction  of  the  lower  with  the  middle  third  of  the  thigh  for 
all  fractures  of  either  or  both  bones  of  the  leg ;  except  fract- 
ures of  the  internal  or  external  malleolus  without  deformity. 
For  the  latter  it  is  not  necessary  that  the  dressing  should 
extend  above  the  tubercle  of  the  tibia.  As  has  been  stated, 
the  knee-joint  being  slightly  flexed  during  the  application 
of  the  fixed  dressing,  it  remains  in  this  position  throughout 
the  treatment.  In  order,  therefore,  to  give  the  limb  com- 
fortable support  a  light  pillow  should  be  kept  beneath  the 
leg.  In  fractures  about  the  ankle,  if  the  tendency  of  the 
deformity  is  to  inversion  of  the  foot,  care  must  be  taken 
while  applying  the  plaster-of-Paris  dressing  that  this  ten- 
dency be  entirely  corrected.  In  like  manner,  if  the 
deformity  inclines  to  thrust  the  foot  forward  or  allow  it 
to  droop  backward,  critical  inspection  of  its  profile  will 
demonstrate  whether  these  tendencies  have  been  satisfactorily 
overcome.  In  Pott's  fracture,  the  rule  is  different  ;  the  foot 
being  everted,  it  is  necessary  not  only  to  bring  it  back  to 
the  proper  line,  but  also  beyond  that  line,  even  into  a  posi- 
tion of  moderate  inversion.  Slight  traction  upon  the  external 
lateral  ligament  is  thus  made,  and  through  it  upon  the  lower 
fragment.  Excellent  coaptation  can  in  this  way  be  obtained. 
Careful  attention  to  this  detail  in  the  application  of  a  fixed 
dressing  for  Pott's  fracture  will  fulfil  all  the  indications 
required.  The  classical  treatment  of  this  fracture  is  by 
Dupuytren's  splint,  which  consists  of  a  straight  splint  ex- 
tending from  the  knee-joint  to  the  sole  of  the  foot,  so  applied 


130  A    CLINICAL    TREATISE    ON  FRACTURES. 

that  when  placed  upon  the  inner  aspect  of  the  leg  the  pad- 
ding will  support  the  tibia  throughout  its  length,  while  the 
deformity  is  corrected  by  bandaging  the  foot  to  the  splint 
so  that  it  will  be  retained  in  a  state  of  moderate  inversion. 
But  this  dressing  will  seldom  be  found  to  fulfil  the  require- 
ments as  well  as  the  method  of  application  of  plaster-of-Paris 
bandaging  just  described.  The  plaster-of-Paris  dressing  may 
be  retained  for  four  weeks,  in  all  cases,  whether  employed 
for  fracture  of  one  or  both  bones  of  the  leg,  for  while  union 
may  occur  sooner  than  this  in  certain  localities,  and  under 
peculiarly  favorable  circumstances,  it  is  not  a  union  of  suf- 
ficient firmness  to  bear  weight.  At  the  end  of  four  weeks, 
the  dressing  having  been  cut  and  removed,  careful  examina- 
tion should  be  made  of  the  limb  in  order  to  ascertain  as 
definitely  as  possible  the  conditions  existing  at  the  seat  of 
fracture.  If  union  appears  firm,  complete  rest,  afforded  by 
the  adjustment  of  two  lateral  cardboard  splints  for  two 
weeks  more,  should  be  continued.  At  the  end  of  this 
period  slight  weight  may  be  borne  by  the  leg,  though  the 
patient  should  still  be  upon  crutches  for  another  week. 
Should  it  be  found  upon  examination,  on  the  other  hand, 
that  there  is  little  or  no  attempt  at  union  at  the  seat  of 
fracture,  time  will  be  saved  by  applying  a  fresh  plaster-of- 
Paris  bandage,  because  if  little  or  no  union  occurs  in  four 
weeks,  union  will  not  be  completely  firm  in  six. 

While  these  observations  are  general,  they  apply  to  almost 
every  fracture  of  the  leg.  Union  does  not  occur  so  quickly 
if  deformity  remains,  if  both  bones  are  broken,  if  fixation 
has  been  incomplete,  or  if  there  has  been  fracture  of  one  or 


FRACTURES    OF   THE   LOWER   EXTREMITY.  131 

more  bones  elsewhere.  When  it  may  be  assumed,  therefore, 
that  for  any  reason  union  will  be  more  or  less  delayed,  it  is 
quite  proper  to  allow  the  original  dressing  to  remain  undis- 
turbed for  six  or  seven  weeks ;  always  remembering,  how- 
ever, that  more  or  less  temporary  rigidity  of  the  ankle-  and 
knee-joints  will  result  from  such  protracted  confinement. 

The  ambulatory  treatment  of  fractures  of  the  lower  ex- 
tremity relates  principally  to  fractures  of  the  leg.  It  is 
designed  to  retain  the  fragments  in  a  state  of  such  fixation 
that  the  ordinary  movements  incident  to  the  patient's  being 
up  and  about  will  not  disturb  them.  It  is  recommended 
on  the  ground  that  by  preserving  the  general  health  and 
strength  the  fracture  benefits ;  that  the  reparatory  processes 
show  greater  activity  than  when  the  recumbent  posture  is 
maintained  ;  and  that  the  prospect  of  early  union  is  thereby 
increased.  The  cases  to  which  it  may  be  applicable,  there- 
fore, are  those  to  whom  confinement  to  bed  proves  injurious. 
It  is  a  measure  requiring  so  much  skill  to  insure  the  avoid- 
ance of  any  mishap  that  it  cannot  perhaps  be  prudently 
recommended  for  general  use. 

FRACTURES  OF  THE  PATELLA. 

The  functions  and  location  of  the  patella  are  such  that 
not  only  is  it  constantly  and  normally  subjected  to  great 
tensile  strains  in  the  ordinary  performance  of  the  movements 
of  the  lower  extremity  ;  but  it  is  also  very  liable  to  injury 
either  from  the  excess  of  these  normal  strains,  or  from  blows 
and  falls.  The  tensile  strain  conveyed  through  the  patella, 
by  the  action  of  the  quadriceps  extensor  muscle  acting  upon 


I32  A    CLINICAL    TREATISE    OX  FRACTURES. 

a  lever  of  such  immense  disadvantage,  with  such  a  range 
of  action,  is  great,  even  in  the  performance  of  the  most 
simple  movements  of  extension  of  the  leg ;  such  movements 
as  ascending  steps,  mounting  a  horse,  and  the  like  ;  while 
in  running,  jumping,  and  various  athletic  performances,  and 
the  heavy  work  done  by  many  mechanics  the  strain  becomes 
inordinate.  The  bone,  however,  rarely  gives  way  under  these 
circumstances.  When  fractured  by  muscular  action  other 
conditions  will  invariably  be  found  to  have  accompanied  the 
strain.  The  muscle  acting  on  the  patella  has  been  sur- 
prised, so  that,  instead  of  the  strain  being  put  upon  the 
patella  voluntarily,  it  has  come  unexpectedly,  and  hence 
with  a  jerk ;  this  fact  is  frequently  shown  by  the  existence 
of  fracture  of  the  patella  of  an  individual  who  could  not 
voluntarily  exert  sufficient  power  with  his  muscles  to  pro- 
duce the  result,  but  who  in  falling  backward,  and  attempting 
to  catch  himself  with  one  leg,  has  suddenly  applied  the 
strain  in  a  spasmodic  effort  to  resist  the  flexing  of  his  knee. 
Another  condition  which  I  believe  is  a  frequent  con- 
comitant of  muscular  action  in  producing  fracture  of  the 
patella  is  impact  upon  the  bone  while  it  is  being  subjected 
to  tensile  strain.  In  fractures  in  which  it  can  be  demon- 
strated that  the  lesion  is  caused  by  muscular  action,  the 
subordinate  element  of  direct  impact  may  well  be  looked  for; 
while  in  the  smaller  group  of  fractures  produced  by  direct 
impact  careful  analysis  of  the  method  of  production  of  the 
fracture  will  not  infrequently  reveal  the  coexistence  of  the 
element  of  muscular  action.  After  numerous  tests,  which 
were  made  with  difficulty  because  of  the  inability  to  grip  the 


FRACTURES    OF   THE   LOWER   EXTREMITY.  I  33 

tendon  of  the  quadriceps  firmly  enough  to  prevent  its  being 
pulled  out  under  a  strain  of  between  six  and  seven  hundred 
pounds,  a  patella  belonging  to  a  subject  twenty-seven  years 
of  age  was  subjected  to  a  tensile  strain  of  1845  pounds. 
This  reading  was  recorded  at  the  instant  of  rupture  of 
the  ligament  of  the  patella,  and,  therefore,  it  did  not  repre- 
sent the  strength  of  the  bone.  If  the  patella  can  resist  such 
a  pull  as  this,  there  must  be  other  elements  contributing 
to  its  fracture  in  those  cases  which  are  regarded  as  fractures 

Fig.  67. 


Skiagraph  of  recent  transverse  fracture  of  the  patella. 

from  muscular  violence  alone.  For  one,  it  is  certainly  true 
that  the  bone  is  subjected  to  a  strain  produced  by  forces 
acting  not  in  line,  but  at  a  greater  or  less  angle  to  one 
another,  and  that  the  patella  by  the  resultant  of  these  forces 
is  broken  over  the  condyles  of  the  femur  as  a  stick  may  be 
broken  over  one's  knee.  Possibly  another  element  is  sug- 
gested by  the  position  assumed  by  the  fragments  after  fract- 
ure.    Fig.  67,   a  skiagram  of  a  recent  fracture,   shows  a  tilt 


134  A    CLINICAL    TREATISE    ON  FRACTURES. 

of  the  fractured  surfaces  in  divergent  directions  from  one 
another,  a  condition  frequently  observed.  If  this  tendency 
exists  whilst  the  limb  is  in  a  state  of  complete  extension,  it 
would  evidently  be  increased  progressively  by  flexion,  and 
the  greater  the  flexion  the  more  would  the  force  of  the  mus- 
cular effort  be  concentrated  on  the  exterior  surface  of  the 
bone,  instead  of  being  distributed  uniformly  throughout  its 
substance.  If  this  view  is  entertained,  the  curious  proposi- 
tion presents  itself,  that  the  bone,  so  far  as  the  texture  of 
its  surfaces  is  concerned,  is  from  a  mechanical  point  of 
view  structurally  deficient,  because  the  exterior  surface  of 
compact  character  is  better  fitted  to  resist  crushing  than 
tensile  strain,  and  the  inferior  surface  of  dense,  fibrous, 
more  elastic  material  is  better  able  to  withstand  stretching. 
The  variety  of  fracture  when,  as  so  often  happens,  no 
satisfactory  account  can  be  got  of  the  manner  in  which 
it  was  caused,  may  often  indicate  its  probable  manner  of 
production  ;  thus  a  longitudinal  fracture  without  displace- 
ment may  be  attributed  with  some  certainty  to  direct 
impact.  To  the  latter  may  also  be  attributed  every  instance 
of  comminuted  fracture  ;  and  it  is  hardly  necessary  to 
mention  that  contusion  and  laceration  of  the  integument 
over  the  patella  usually  leave  no  room  for  doubt  regarding 
the  manner  in  which  the  fracture  was  caused.  In  a 
transverse  fracture — the  variety  observed  in  such  a  great 
preponderance  of  cases  that  the  term  fracture  of  the  patella, 
if  unqualified,  has  come  to  signify  transverse  fracture — the 
extent  of  separation  of  the  fragments,  while  not  in  the  least 
conclusive,   probably  in    many  cases  bears  some  relation  to 


FRACTURES   OF  THE   LOWER   EXTREMITY.  1 35 

the  causation  of  the  injury.  If  the  separation  is  great,  the 
indication  favors  muscular  violence  ;  while  if  slight,  direct 
impact.  Separation  of  the  fragments,  however,  depending, 
as  it  does,  on  other  conditions  than  those  obtaining  at  the 
moment  of  injury,  can  hardly  be  considered  as  of  much  value 
in  reaching  a  decision  regarding  the  method  of  production 
of  the  fracture.  Such  fractures  usually  occur  somewhat 
below  the  middle  of  the  bone,  as  shown  in  Fig.   68. 

Fig.  68. 


Skiagraph  of  transverse  fracture  of  the  patella. 

Diagnosis.— Pain,  loss  of  function,  and  the  frequent 
consciousness  of  the  patient  that  he  has  felt  something  give 
way  in  his  knee,  and  at  times  has  observed  an  audible  snap, 
sufficiently  attract  the  attention  of  the  surgeon  to  the  prob- 
able existence  of  fracture.  Examination  of  the  knee-joint, 
even  very  shortly  after  the  occurrence  of  the  injury,  reveals 
marked  effusion.  On  palpation  a  distinct  sulcus,  varying 
in  width  according  to  the  degree  of  separation  of  the  frag- 


136  A    CLINICAL    TREATISE    ON  FRACTURES. 

ments,  is  clearly  felt  (or  it  may  be  seen,  Fig.  69),  as  also  are 
the  fragments.  The  upper  fragment  is  usually  observed  to 
be  larger  than  the  lower  fragment,  constituting  perhaps  two- 
thirds  of  the  dimensions  of  the  bone.  Crepitus  may  be 
elicited  (1)  if  there  is  no  interposition  of  soft  tissue,  and  (2) 
if  the  displacement  of  the  fragments  can  be  sufficiently  over- 
come to  bring  them  into  contact.  Ability  to  obtain  crepitus 
furnishes  an  important  suggestion  regarding  the  treatment. 
If  crepitus  be  elicited  by  swaying  the  fragments  laterally 
with  the  thumbs  and  fingers,  seizing  each  and  bringing  them 
together  with  the  exercise  of  little  force,  it  indicates  not  only 
that  the  separation  present  is  readily  overcome,  but  also 
demonstrates  the  absence  of  any  considerable  quantity  of 
shreds  of  capsule,  other  tissues,  or  blood-clots  between  them. 
While   simple   transverse  fracture  is  usually  easy  to  recog- 

FlG.  69. 


Recent  transverse  fracture  of  the  patella. 

nize,  fractures  unaccompanied  by  separation  may  often  be 
overlooked,  particularly  if  there  is  severe  contusion  of  the 
overlying  integument.  In  this  group,  although  commin- 
uted fractures  are  occasionally  found,  a  longitudinal  fracture 
occupying  the  median  line  of  the  bone  is  the  one  most 
difficult  to  detect,  even  after  careful  examination.  Seizing 
the   bone   laterallv,   instead  of  above   and   below,  with   the 


FRACTURES    OF   THE   LOWER   EXTREMITY.  1 37 

thumbs  and  fingers,  an  effort  at  vertical  swaying  may  give 
faint  crepitus,  with  almost  imperceptible  mobility. 

Treatment. — The   object  sought  in   any  plan  of  treat- 
merit  is    not  only    to   get  as  close    union   of    fragments   as 
possible   by  a  uniting    medium   which   will   resist,   without 
breaking  or  stretching,  subsequent  strains  to  which  it  will 
be  put,   but  also  to  prevent  future  impairment  of  function 
resulting  from  rigidity  of  the   knee-joint  or  of  the  patella 
itself.      It  may  be  that  efforts  to  obtain  either  bony  or  very 
close  fibrous  union  have  at  times  occupied  so  much  atten- 
tion,  that  sufficient  care  has  not  been  given  to  that  other 
important    element    in    the    cure,    the    perfect    flexion    and 
extension  of  the  knee-joint.     Impairment  of  motion  of  the 
knee-joint  after  fracture  of  the  patella  depends,  on  the  one 
hand,  upon  the  inflammatory  exudates  following  the  original 
injury,  or  produced  by  some  irritating  element  in  the  treat- 
ment or  by  some   constitutional    peculiarity  of  the   patient 
which    impedes   recession  of  inflammatory   processes  ;    and, 
on  the  other  hand,   by  too  long  retention  of  some  fixed  or 
permanent  dressing,  which,  while  intended  to  perfect  union 
of  the   fragments,  will,  when   removed,   be  found  to   have 
also,  incidentally,  caused  partial  or  complete  rigidity  of  the 
knee-joint  very  difficult  to  overcome. 

The  methods  of  treatment  may  be  divided  into  two 
classes,  the  operative  and  the  non-operative.  In  determin- 
ing upon  a  choice  between  these,  apart  from  the  individ- 
ual preference  of  the  surgeon,  the  degree  of  separation  of 
the  fragments,  the  ability  to  bring  them  into  close  approx- 
imation, the  evidences  of  intervention  of  periosteal  or  other 


I38  A    CLINICAL    TREATISE    ON  FRACTURES. 

tissues,  the  perfection  of  asepsis  and  surgical  technique 
attainable,  and  the  age  and  health  of  the  patient,  are  general 
factors  to  be  considered  in  reaching  a  decision.  In  most 
cases  of  fracture  of  the  patella  operation  is,  in  my  opinion, 
inadvisable.  The  cases  in  which  operation  may  be  desirable 
are  those  where  there  is  a  very  wide  separation  of  the  frag- 
ments, evidence  of  the  intervention  of  an  unusual  amount 
of  soft  tissue  between  the  fragments,  and  the  failure  of 
efforts  to  obtain  anything  like  a  close  approximation  of 
them,  either  by  efforts  with  the  fingers  or  some  one  of  the 
various  devices  which  may  have  been  employed  for  the  pur- 
pose. Those  cases  which  either  after  the  lapse  of  weeks 
show  no  tendency  to  unite,  or  months  or  years  after  the 
fracture  present  themselves  for  treatment,  because  of  inter- 
ference with  function  from  widely  stretched  fibrous  union 
or  no  union  at  all,  are  clearly  suitable  for  operation; 
provided  the  conditions  mentioned  above  favor  its  perform- 
ance. Certain  it  is,  however,  that  operation  should  under 
any  circumstances  be  contemplated  only  by  the  practised 
hand,  under  conditions  which  may  be  regarded  as  surgic- 
ally perfect.  Of  the  various  operations  practised,  the  open 
method  is  to  be  preferred,  because  (1)  it  insures  nice  contact 
with  the  opportunity  to  remove  all  material  which  has 
become  interposed  between  the  fragments.  (2)  While  more 
formidable  in  appearance,  it  has  proved  equally  safe  with 
the  subcutaneous  method.  The  latter  makes  no  attempt 
at  brinsfinsf  fractured  bone  surfaces  in  contact,  freed  from 
interposed  tissue,  and,  therefore,  fails  to  meet  one  of  the 
chief  indications  for  operative  interference.     While  a  great 


FRACTURES    OF   THE   LOWER   EXTREMITY.  1 39 

number  of  appliances  have  been  devised  and  are  used  for 
the  management  of  this  fracture,  the  object  sought  alike 
in  them  all  is  to  effect  close  approximation  and  retention 
of  the  fragments  until  union  has  occurred.  Since  in 
the  separation  the  upper  fragment  is  the  one  principally 
at  fault,  to  it  efforts  at  approximation  must  be  mainly 
directed.  The  lower  fragment  remains  practically  in  situ, 
and  is  brought  up  to  its  highest  level  by  complete  extension 
of  the  leg.  This  done,  very  little  more  attention  need  be 
paid  to  it,  than  that  it  shall  be  kept  at  rest.  At  the  end 
of  five  days  or  a  week  pain,  effusion,  and  swelling  about 
the  joint  will  have  subsided,  and  the  irritability  of  the 
quadriceps  extensor,  due  to  its  having  lost  its  power  of 
action,  will,  when  the  muscle  has  become  accustomed  to  its 
altered  conditions,  relax.  Then,  and  not  before,  will  any 
form  of  apparatus  be  of  use.  During  this  period,  elevation 
of  the  limb  in  some  splint  which  will  keep  it  at  rest  will, 
with  the  use  of  an  evaporating  lotion,  be  found  sufficient 
to  promote  absorption  of  the  effused  products.  But  some 
surgeons  apply  an  elastic  rubber  bandage  to  the  knee  for 
several  days  after  the  injury.  If  it  is  purposed  to  use  elastic 
or  other  pressure,  a  warning  to  be  borne  in  mind  is,  that 
pressure  of  any  sort  does  harm  to  what  may  be  called  an 
ascending  inflammation.  Not  until  the  latter  shows  the 
first  signs  of  receding,  as  evidenced  by  improvement  in 
color,  temperature,  and  texture  of  the  skin,  is  pressure 
applicable.  Aspiration  of  the  knee-joint  is  sometimes 
used,  without  waiting  for  absorption,  with  a  view  of  get- 
ting  rid  of  the    effused    products   at   once.       A    like   result 


1/j.O  A    CLINICAL    TREATISE    ON  FRACTURES. 

has    been    satisfactorily    obtained,     more     deliberately,     by 
massage. 

Probably  the  plan  of  non-operative  treatment  in  most 
common  use  may  be  in  general  terms  described  as  follows: 
the  limb,  with  the  leg  slightly  elevated,  is  placed  upon  a 
straight  posterior  splint;  a  compress  is  applied  above  the 
upper  fragment  and  secured  to  the  splint  in  such  a  manner 
as  to  produce  downward  traction;  a  roller  bandage  retains 
the  whole  apparatus;  and  the  limb  is  elevated  on  pillows 
or  an  inclined  plane.  If  the  posterior  splint  be  a  broad 
one,  provided  with  cross-pieces,  rotatiug-pins,  or  notched 
edges,  these  furnish  points  of  attachment  for  the  strips 
which  draw  down  the  compress  above  the  upper  fragment. 

Malgaigne's  hooks,  which  are  usually  considered  among 
the  non-operative  methods  of  treatment,  have  their  advo- 
cates. The  apparatus  consists  of  hooks  arranged  to  fasten 
above  the  upper  and  below  the  lower  fragment,  and  so 
placed  as  to  be  approximated  by  a  screw  working  on  a  bar 
connecting  them.  Their  method  of  application  is  as  fol- 
lows: the  skin  about  the  knee-joint  having  been  repeatedly 
sterilized  during  a  period  of  at  least  twenty-four  hours,  and 
the  usual  aseptic  technique  having  been  carried  out,  the 
upper  fragment  is  brought  down  and  held  in  as  accurate 
apposition  as  possible  by  the  hands  of  an  assistant.  The 
lower  pair  of  hooks  is  inserted  with  sufficient  force  to  insure 
the  engagement  of  its  points  into  the  lower  portion  of  the 
lower  fragment,  the  integument  meanwhile  being  slightly 
drawn  downward.  The  integument  is  then  drawn  upward 
until  it  is  quite  tense,  and  the  upper  pair  of  hooks  is  made 


FRACTURES   OF   THE   LOWER   EXTREMITY. 


141 


to  engage  firmly  in  the  upper  portion  of  the  upper  frag- 
ment. Coupling  of  the  parts,  so  that  the  screw  may  act,  is 
readily  done  by  a  little  adjustment.  The  screw  is  set  up 
by  a  key  with  a  number  of  turns  sufficient  to  make  a  nice 
coaptation  of  the  fragments,  without  risk  of  dragging  out 
the  hooks,  and  the  application  is  completed  by  insinuating 
a  small  quantity  of  gauze  beneath  and  around  the  instru- 
ment.     If  the   integument  has  been  properly  drawn  upon 

Fig.  70. 


Author's  Indian  puzzle  apparatus  for  fracture  of  the  patella,  showing  the  basket-like 
arrangement  of  adhesive  straps  upon  the  thigh  with  the  extension  applied. 

before  inserting  the  upper  and  lower  pair  of  hooks,  an 
objectionable  puckering  of  it  between  the  latter  will  be 
avoided. 

In  the  cases  in  which  it  has  been  decided  not  to  operate, 
the  choice  of  the  mode  of  treatment  most  appropriate  for 
the  conditions  which  present  themselves  must  be  deter- 
mined by  the  circumstances  of  the  individual  case. 

The  apparatus  shown  in  Fig.  70  is  one  I  have  long  used, 
and  prefer.     It  will  be  seen  to  act  like  an   Indian  puzzle, 


I42  A    CLINICAL    TREATISE    OX  FRACTURES. 

which  is  a  small  cylinder  of  wickerwork,  and  which, 
owing  to  its  peculiar  arrangement,  closes  more  tightly 
about  the  finger  the  more  it  is  drawn  upon.  The  appa- 
ratus consists  simply  of  a  basket-like  series  of  half-inch 
rubber  straps,  so  applied  that  their  lower  ends  terminate 
at  points  to  the  outer  and  inner  side  of  the  knee  and  are 
attached  to  rings.  To  these  the  ordinary  extension  appa- 
ratus with  pulley  and  weight  of  about  six  pounds  is  fas- 
tened. This  part  of  the  apparatus  is  intended  to  relax 
and  draw  down  all  the  tissues  of  the  thigh,  while  traction 
upon  the  upper  fragment  of  the  patella  is  obtained  by  two 
or  three  rubber  straps  carried  across  the  latter  and  made  fast 
to  the  rings.  After  the  appliance  has  settled  into  place  the 
lower  fragment  may,  if  necessary,  be  supported  by  one  or 
two  straps  carried  upward.  The  essential  feature,  and  the 
only  one  which  is  novel  in  the  device,  is,  of  course,  the 
basket-like  arrangement  of  the  straps,  as  extension  with 
adhesive  plaster  or  leather  has  long  been  employed.  It  is 
very  comfortable  to  the  patient  and  entirely  satisfactory  in 
all  cases  where  there  is  not  too  great  separation  of  frag- 
ments. It  paralyzes  the  muscles  of  the  thigh  by  its  steady, 
unremitting  pressure,  and  draws  down  the  upper  fragment, 
and  yet  causes  no  tendency  to  swelling  of  the  limb  below, 
no  harsh  pressure  upon  the  integument  over  the  upper 
fragment,  as  may  be  caused  by  a  compress  held  firmly  in 
place  by  adhesive  plaster,  and  no  infiltration  of  the  tissues 
about  the  knee,  so  often  observed  when  firm  straps  are 
applied  to  the  lower,  as  well  as  the  upper  fragment.  While 
not  criticising  the  various  methods  based  on  other  princi- 


FRACTURES   OF   THE   LOWER   EXTREMITY.  143 

pies,  it  may  be  proper  to  observe  that  any  one  of  them  is 
likely,  unless  carefully  and  judiciously  used,  to  keep  up  or 
increase  the  irritation  and  consequent  infiltration  about 
the  joint,   and  thus  retard  repair. 

The  extension  apparatus  remains  on  undisturbed  through- 
out the  treatment,  or  may  require  renewal  once.  The 
limb  is  allowed  to  rest  upon  a  long  pillow,  with  a 
cradle  to  keep  the  bed-clothes  off  the  toes.  It  has  been 
found  desirable  during  the  course  of  treatment  with  this 
apparatus  to  make,  every  day  or  two,  movements  of  the 
knee-joint  by  elevating  it  gently  about  three  inches  from 
the  bed,  without  removing  the  extension  weights,  provided 
this  can  be  done  without  provoking  muscular  contraction 
upon  the  upper  fragment.  When  such  passive  movements 
can  be  conducted  without  retarding  union,  much  time  in 
the  complete  restoration  of  motion  is  gained.  Depending 
upon  the  firmness  of  the  union  observed,  the  apparatus  is 
retained  for  a  period  of  from  five  to  seven  weeks,  at  the  end 
of  which  the  patient  is  allowed  up,  with  some  simple  device 
provided  to  support  the  upper  fragment  for  a  month  or  more 
longer.  A  plaster-of-Paris  dressing  is  seldom  required,  and 
in  my  opinion  is  usually  undesirable,  not  only  because  it 
prevents  all  motion  of  the  knee-joint,  but  because,  having 
slackened  out  when  dried,  it  does  not  check  the  action  of 
the  quadriceps  upon  the  upper  fragment,  when  the  patient 
is  up  and  about  on  crutches. 

For  practical  purposes  operations  for  simple  fracture  of 
the  patella  may  be  divided  into  (1)  those  performed  through 
an    incision   exposing    the  joint,    and    (2)    those  which    are 


144  A    CLINICAL    TREATISE    OX  FRACTURES. 

performed  subcutaneously.  The  open  method  is  in  most 
cases  obviously  much  better  adapted  to  meet  the  conditions 
than  any  form  of  subcutaneous  operation  could  possibly  be, 
for  the  points  which  indicate  operation  may  be  briefly  restated 
as  follows:  to  clear  out  extraneous  tissue,  blood-clots,  etc., 
which  interfere  with  approximation  of  fragments,  and  to 
bring  the  fragments  together  and  secure  their  fractured 
surfaces  in  apposition.  On  the  other  hand,  the  dangers 
attendant  upon  the  open  method  are  not  avoided  by  the 
use  of  the  subcutaneous  plan  because  infection  can  occur 
as   readily  along  a  suture-track  as  in  an  open  wound. 

There  are  many  plans  by  which  the  open  operation  may 
be  performed,  but  the  essential  steps  are:  (i)  an  absolutely 
perfect  aseptic  technique  ;  (21  by  an  incision  five  inches 
long,  carried  down  directly  in  front  of  the  joint,  the  interior 
of  the  joint  should  be  thoroughly  exposed;  (3)  the  fract- 
ured surfaces  should  be  brought  in  close  apposition,  all 
intervening  substances  being  removed  ;  (4)  the  edges  of  the 
periosteum  and  the  tendon  of  the  quadriceps  and  ligament 
of  the  patella  should  be  united  by  chromicized  catgut,  silk- 
worm-gut, or  kangaroo-tendon  sutures;  (5)  the  wound  should 
be  closed  by  continuous  silk  or  gut  suture;  and  no  drain- 
age being  necessary,  a  dressing  applied,  and  the  limb  placed 
at  rest  with  the  foot  elevated.  But  few  surgeons  now 
attempt  to  secure  the  fragments  by  drilling  the  bone,  the 
sutures  in  the  periosteum  and  through  the  tendon  and 
ligament  of  the  patella  being  sufficient  for  that  purpose. 
If  the  subcutaneous  method  of  operation  is  used,  that 
which    is  known    by    the  name    of  Barker  is  probably    the 


FRACTURES   OF   THE   LOWER   EXTREMITY.  145 

most  popular.  This  consists  in  passing  a  curved  pedicle 
needle  under  the  patella  from  below  upward,  entering  at 
a  point  just  beneath  the  inferior  extremity  of  the  lower 
fragment  which  will  carry  it  through  the  middle  of  the 
ligamentum  patellae,  behind  the  lower  fragment  upward 
behind  the  upper  fragment  through  the  middle  of  the  tendon 
of  the  quadriceps,  whence  it  emerges.  Re-entering  at  this 
point,  freshly  armed  with  the  free  end  of  the  ligature,  the 
needle  is  carried  downward  in  front  and  in  close  proximity 
to  the  upper  fragment,  and  continued  in  a  similar  manner 
in  front  of  the  lower  fragment  until  it  reaches  the  primary 
point  of  entrance.  Emerging  from  there  and  unthreaded, 
the  needle  is  withdrawn ;  the  two  free  ends  being  drawn 
upon  when  tied  will  complete  a  loop  including  in  it  both 
fragments.  The  knot  is  allowed  to  drop  into  the  skin 
opening.  Stimson  formerly  used  a  subcutaneous  method 
devised  by  himself,  and  which  is  known  by  his  name.  He 
frankly  states,  however,  that  the  dangers  of  infection  through 
the  points  of  entrance  and  exit  of  sutures  is  so  great  that 
he  has  abandoned  it,  and  now  uses  only  the  open  method. 
In  every  case  of  simple  fracture  of  the  patella  in  which 
the  question  of  operation  is  raised,  one  should  consider  that 
the  operation  is  not  at  all  necessary  as  a  life-saving  meas- 
ure ;  that  it  is  attended  with  very  considerable  risk  unless 
done  under  absolutely  perfect  surgical  conditions;  and  that 
non-operative  treatment  without  being  attended  by  any  of 
these  risks  is  often  perfectly  successful.  The  only  persons 
qualified  to  perform  the  operation  are  surgeons  of  experi- 
ence, who  have  at  their  command  the  technique  only  to  be 
10 


146 


A    CLINICAL    TREATISE    ON  FRACTURES. 


obtained  in  a  properly  equipped  hospital.  The  patient  must 
not  be  enfeebled,  nor  suffering  from  visceral  disease,  as  such 
persons  succumb  readily  to  its  perils.  The  dangers  attend- 
ant upon  the  operation  should  be  fully  stated  to  the  patient 
at  the  time  his  consent  to  it  is  sought.  The  operation 
should  be  reserved  for  cases  in  which  there  is  wide  separa- 
tion of  fragments,  extensive  lateral  tears  of  aponeurosis,  or 
the  presence  of  extraneous  matter  between  fragments,  simul- 
taneous fracture  of  both  bones,  and,  as  a  secondary  measure, 
either  after  failure  of  other  treatment  or  after  refracture.  The 
open  method  is  the  only  one  to  be  considered.  It  must  be 
aided  by  early  massage  and  mobilization  of  the  joint. 

Perfect  motion  of  the  knee-joint  after  fracture  of  the 
patella  is  indispensable  to  the  complete  restoration  to  func- 
tion of  the  limb.  Indeed,  if  the  alternative  were  presented 
of  a  closely  united  patella  with  a  rigid  knee-joint,  or  an 
imperfectly  united    patella  with    a  movable   knee-joint,   the 

latter  would  usually  be  ac- 

FlG.  71.  J 

cepted  as  a  lesser  evil  than 
the  former.  A  case  of  old 
fracture  of  the  patella  came 
under  my  observation  which 
strikingly  illustrated  this 
matter.  It  had  never,  either 
at  the  time  of  its  occurrence 

Wide  separation  of  fragments  after  fracture       n0r     Subsequently,      received 

of  the  patella.  any  treatment.     The  upper 

fragment  was  drawn  far  up  the  thigh,  and  had  no  connec- 
tion  whatever   with    the   lower   fragment.     The   knee-joint 


FRACTURES    OF   THE   LOWER   EXTREMITY. 


1 47 


was  so  freely  movable  that  the  leg  could  be  flexed  com- 
pletely on  the  thigh.  The  man  walked  on  the  level  with 
a  hardly  noticeable  limp,  and  in  mounting  steps  threw 
his  foot  up  without  apparent  effort.  Fig.  71  is  a  reproduc- 
tion from  a  plaster  cast  I  made  of  the  limb. 

The  result  looked  for  in  any  plan  of  non-operative  treat- 
ment, though  not  bony,  is  much  closer  fibrous  union  than 
that  shown  in  Fig.  72.  Cases  have  come  under  my  observa- 
tion years  after  the  occurrence  of  the  fracture  fig.  73- 
in  which  the  bone  showed  no  trace  of  the 
fig.  72.  original  lesion,  but  was  smooth, 
firm,  and  movable,  and  the  re- 
sult to  all  appearances  ideal ; 
nevertheless  the  union,  even  in 
these,  was  probably  a  close 
fibrous  one,  not  bony;  one  which 
would  yield  to  post-mortem 
after   fracture     boiling-      Comminuted   fracture 

of  the  patella. 

of  the  patella,  which  has  been 
thought,  on  account  of  the  greater  inflammatory  reaction 
following  the  violence  of  the  direct  impact  producing  it, 
to  unite  with  a  stronger  and  more  durable  fibrous  band 
than  transverse  fracture,  is  well  illustrated  in  Fig.   73. 


Showing  fibrous 
band  of  union, 


Showing  strong  fi- 
brous union,  after 
comminuted  fract- 
ure of  the  patella. 


FRACTURES   OF  THE  FEMUR. 

Fractures  of  the  femur  may  be  considered  under  three 
headings,  fracture  of  the  shaft,  fracture  of  the  upper  extrem- 
ity, and  fracture  of  the  lower  extremity.  At  any  point  the 
injury  is  described  as  fracture  of  the  thigh.     Unlike  fract- 


I48  A    CLINICAL    TREATISE    ON  FRACTURES. 

ures  of  the  leg,  which  possess  many  characteristics  in  com- 
mon, fractures  of  the  femur  differ  widely  according  to  their 
locality  in  many  features  relating  to  their  history. 

Fractures  of  the  Shaft. — Like  fractures  in  other  long 
bones,  fractures  of  the  shaft  of  the  femur  incline  to  be 
oblique,  if  produced  by  indirect  violence ;  and  transverse 
when  they  are  produced  by  direct  impact,  though  not  in 
so  marked  a  degree  as  in  the  humerus  or  tibia.     Fracture 

fig.  74. 


Recent  fracture  of  the  femur,  before  reduction. 

at  any  point  of  the  shaft,  if  complete,  almost  invariably 
causes  overlapping  of  the  fragments,  and  the  consequent 
shortening  of  the  limb  indicates  approximately  the  degree 
of  that  overlapping.  The  directions  assumed  by  the  two 
fragments,  while  depending  upon  the  direction  of  the  plane 
of  fracture,  are  in  many  instances  anterior  deflection  of  the 
upper  fragment  and  posterior  deflection  of  the  lower  frag- 
ment, accompanied  by  more  or  less  rotation  outward  of  the 
latter.  The  characteristic  appearance  of  the  deformity 
produced    is   well    shown    in    the    photograph    of    a   recent 


FRACTURES   OF  THE  LOWER  EXTREMITY. 


I49 


fracture,  reproduced  in  Fig.  74;  while  the  tendency  of  the 
fragments  to  the  overlapping,  rotation,  and  angularity  is 
graphically  illustrated  is  Figs.  75,  76,  and  yy,  which  repre- 


fig.  75. 


Fig.  76. 


Fig.  77. 


Union  after  fracture  of 
the  femur  with  slight 
bowing,  marked  rota- 
tion outward  of  lower 
fragment,  and  little 
overlapping. 


Union  after  fracture  of 
the  femur  with  marked 
overlapping,  angular- 
ity, and  rotation  out- 
ward of  the  lower  frag- 
ment. 


Union  after  fracture  of 
the  femur  with  marked 
overlapping  and  slight 
rotation  inward  of  the 
lower  fragment. 


sent  a  series  of  specimens  of  firmly  united  fractures  with 
varying  degrees  of  deformity.  Though  great  force  is 
required  to  fracture  the  femur  of  a  healthy  adult,  less 
damage  is  frequently  done  to  the  soft  parts  than  would  be 
expected.     This,   no  doubt,   is  partly  accounted  for  by  the 


i5o 


A    CLINICAL    TREATISE    ON  FRACTURES. 


Fig.  78. 


Incomplete      fract 
of  the  femur. 


fact  that  the  bone  lies  so  deeply  imbedded  in  strong  fasciae 
and  muscles-  To  this  is  also  due  the  comparative  infre- 
quency  of  compound  fracture  caused  by  pene- 
tration of  the  integument  by  a  fragment. 

Diagnosis. —Diagnosis  of  fracture  of  the 
shaft  of  the  femur  is  usually  extremely  sim- 
ple. Loss  of  the  natural  contour  of  the 
thigh,  which  is  particularly  manifest  in  its 
shortening  and  thickening  (Fig.  74);  deform- 
ity in  some  one  direction,  usually  anterior 
bowing ;  eversion  of  the  foot,  leg,  and  knee 
are  signs  which  frequently  upon  inspection 
alone  reveal  the  presence  of  fracture.  Pain 
on  motion  is  severe,  preternatural  mobility 
becomes  at  once  apparent  on  lifting  the 
limb,  and  crepitus  may  be  elicited,  if  the  overlapping 
is  too  slight  to  have  separated  the  fractured  surfaces  of 
upper  and  lower  fragments  from  each  other.  In  incom- 
plete (Fig.  78)  and  green-stick  fractures  (Fig.  79)  there 
can  be  no  crepitus  produced,  but  the  other  signs  may 
all  be  present  in  a  modified  degree.  In  thin  subjects, 
if  a  very  sharp  point  of  either  fragment  can  be  felt, 
information  may  be  obtained  regarding  the  exact  line  of 
fracture.  The  reverse,  however,  is  much  more  often  the 
case,  the  fragments  being  covered  by  a  mass  of  tissue  suf- 
ficient to  mask  not  only  the  line  of  fracture,  but  also  its  exact 
seat.  Fracture  situated  at  the  upper  third  of  the  bone  or 
thereabouts  frequently  causes  troublesome  anterior  displace- 
ment, accompanied  by  rotation  outward  of  the  upper  frag- 


FRACTURES    OF   THE   LOWER   EXTREMITY.  I  5  I 

inent.  An  extraordinary  imitation  of  this  deformity  is  illus- 
trated in  Fig.  79.  The  case  was  one  of  green-stick  fracture 
at  the  junction  of  the  middle,  with  the  upper  third  of  the 
femur  occurring  in  a  child,  whose  femur  was  markedly 
bowed  forward.  Slight  mobility  revealed  the  presence  of 
fracture,  and  as  a  moderate  anterior  curve  was  observed  in 
the  sound  femur  the  combination  of  an  abnormality  and 
a  lesion  was  assumed,  but  it  remained  for  the  skiagraph  to 

Fig.  79. 


Skiagraph  of  a  green-stick  fracture  occurring  in  a  bowed  femur  of  a  child. 

demonstrate  the  true  nature  of  both.  The  fracture  was 
made  complete  and  the  limb  straightened,  as  would  have 
been  done  after  osteotomy.  The  tendency  to  forward  dis- 
placement and  rotation  outward  of  the  upper  fragment, 
produced  principally  by  the  action  of  the  psoas  and  iliacus 
internus  muscles  and  by  the  gluteal  muscles,  increases  the 
higher  up  the  shaft  the  seat  of  fracture  is.  The  combined 
action  of  extensors,  as  well  as  flexors,  through  their  vari- 
ous attachments,  both  direct  and  indirect,  is  to  draw  up  the 


152  A    CLINICAL    TREATISE    ON  FRACTURES. 

lower  fragment.  The  latter,  however,  will  usually  be  found 
to  point  in  a  measurably  straight  direction.  It  causes  the 
overlapping,  but  seldom  contributes  in  any  marked  degree 
to  the  angularity  of  the  deformity,  which  is  produced  almost 
wholly  by  the  position  assumed  by  the  upper  fragment.  The 
shortening  may  not  be  excessive,  but  this  troublesome  ten- 
dency is  quickly  recognized  by  an  ugly  prominence  at  the 
upper  anterior  aspect  of  the  thigh,  which  is  found  difficult 
to  reduce.  The  degree  of  shortening  present,  immediately 
upon  the  receipt  of  the  injury,  is  apt  to  be,  in  an  adult, 
about  three  inches.  It  is  possible  to  reduce  this  shortening, 
in  most  cases  one  half,  by  steady,  moderate  traction  without 
the  aid  of  an  anaesthetic,  the  full  amount  immediately  return- 
ing on  discontinuance  of  the  extension. 

Fractures  of  the  Upper  Bxtremity  of  the  Femur. — 
Fractures  of  the  upper  extremity  may  be  vertical,  involving 
fig.  8q.  _  the  neck  and  shaft  in  a  long   split   which 

does  not  dissolve  the  continuity  between 
the  head  of  the  bone  and  the  shaft  ;  they 
may  involve  the  extreme  upper  extremity 
of  the  shaft ;  the  great  trochanter ;  a  trans- 
verse line  just  below  the  trochanter ;  or, 
finally,  the  neck  of  the  bone,  the  plane  of 
the  fracture  including  the  neck  either  out- 

Intracapsular    fracture  & 

of  the  femur.  side  of   the    capsule,    within   it,    or  partly 

without  and  partly  within  it.  Fig.  80  represents  a  specimen 
of  intracapsular  fracture,  and  Figs.  81  and  82  skiagraphs  of 
recent  extracapsular  fractures.  The  senile  changes  which 
take  place  in  the  structure  and  form  of  the  neck  of  the  femur 


FRACTURES   OF   THE   LOWER   EXTREMITY. 


153 


Fig.  81. 


render  it  so  friable  that  its  fracture  in  the  aged  is  very  com- 
mon.    The  cancellous  structure  undergoes  fatty  changes  and 
its  cells  enlarge.     The  angle  of  the  neck  in  relation  to  the 
shaft,  from  being  obtuse,  gradually  approaches  a  right  angle  ; 
and  this  alteration  in  the  form  of  the  neck  tends  further  to 
weaken  it.     Fracture  of  the  neck  of  the  thigh  in  elderly  per- 
sons is  consequently  often  caused  by  force  only  sufficient  to 
produce   the  most  trifling 
bruise  in  a  young  subject ; 
the  injury  to  the  soft  parts 
accompanying     it,     there- 
fore,   is   often   slight,    and 
the   cause  of  the  fracture 
may  frequently  be  an  ac- 
cident  of  no   greater   im- 
portance   than    a    fall    on 
the    floor.       Fractures    of 
the   trochanter   major  and 
trochanter   minor   are   ex- 
ceedingly   rare,     even    as 
epiphyseal  separations. 

Diagnosis. — The  diag- 
nosis of  fracture  of  the  neck  of  the  femur  is  based  upon 
the  existence  of  marked  pain  increased  upon  the  slightest 
motion,  complete  inability  to  use  the  limb,  or  even  move 
it,  change  in  the  contour  of  the  hip  which  gives  it  a  some- 
what humped  appearance,  and  eversion  of  the  foot  with 
rotation  outward  of  the  leg  and  thigh.  These  symptoms 
alone,  if  present  in  a  subject  over  sixty  years  of  age,  sug- 


Skiagraph  of  a  recent  extracapsular  fracture 
of  the  femur. 


154  A    CLINICAL    TREATISE    OX  FRACTURES. 

gest  the  probability  of  fracture  at  this  point.  A  study  of  the 
change  in  contour  about  the  hip  shows  the  trochanter  major 
to  be  elevated  above  the  line  which  it  normally  occupies. 
This  line,  called  Nelaton's,  extends  from  the  anterior 
superior  spinous  process  of  the  ilium  to  the  tuberosity  of 
the  ischium.  The  change  in  the  position  occupied  by  the 
great  trochanter  likewise  shortens  the  base  of  a  triangle, 
Brvant's,  the  perpendicular  of  which  is  let  fall  from  the 
anterior  superior  spinous  process  of  the  ilium,  the  hypoth- 
enuse  formed  by  carrying  a  line  from  the  anterior  superior 

Fig.  82. 


Skiagraph  of  recent  fracture  of  the  neck  of  the  femur,  occurring  in  a  youthful  subject. 

spinous  process  to  the  great  trochanter,  and  its  base  a  hori- 
zontal line  carried  to  the  perpendicular  (the  patient  being 
in  a  recumbent  position). 

The  trochanter  in  fracture  of  the  neck,  either  intracap- 


FRACTURES    OF   THE   LOWER   EXTREMITY.  I  5  5 

sular  or  extracapsular,  revolves,  when  rotated,  on  the  ilium, 
in  the  arc  of  a  smaller  circle  than  normal,  but  the  distinction 
between  the  arc  of  a  circle  thus  described  is  in  many  sub- 
jects so  difficult  to  make  that  it  will  frequently  be  found 
of  little  clinical  value.  Allis  points  to  relaxation  of  the 
fascia  lata  between  the  ilium  and  the  trochanter  major  as 
furnishing  an  additional  diagnostic  sign  of  fracture  of  the 
neck.  Puckering  of  the  integument  over  the  patella  is 
also  observed  if  the  shortening  be  marked.     To  distinguish 

Fig.  83. 


Skiagraph  of  recent  supracondyloid  fracture  of  the  femur  with  angular 
deformity. 

between  extracapsular  and  intracapsular  fractures  is  in  many 
instances  difficult.  Among  the  numerous  differential  points 
usually  mentioned,  few  will  be  found  to  possess  much  clin- 
ical value.  The  former  occurs  in  younger  subjects  than  the 
latter ;  is  usually  produced  by  greater  violence ;  may  yield 
more  distinct  crepitus  ;  may  present  greater  shortening ;  and 
mav  show  more  contusion  and  discoloration  of  the  integu- 


156 


A    CLINICAL    TREATISE    ON  FRACTURES. 


merit.  But  as  these  signs  are  by  no  means  constant,  the 
evidence  likely  to  be  furnished  by  a  clear  skiagraph  should, 
if  practicable,  be  taken  advantage  of. 

Fractures  of  the  I^ower  Extremity  of  the  Femur. 

— Fractures  of  the  lower  extremity  of  the  femur  may  be 
transverse  or  oblique.  If  the  plane  of  fracture  is  situated 
just  above  the  condyles,  the  fracture  is  called  supracondy- 
loid  (Figs.  83,  84,  and  88);  it  may  involve  the  internal  con- 


FlG. 


Skiagraph  of  recent  oblique  supracondyloid  fracture  of  the  femur,  with  overlapping. 


dyle,  the  line  of  fracture  extending  sometimes  to  a  consider- 
able distance  up  the  shaft;  the  external  condyle  (Fig.  86);  it 
may  be  situated  between  the  condyles  (Fig.  87)  (intercon- 
dyloid);  or  the  line  of  fracture,  involving  not  only  separa- 
tion of  the  condyles  from  the  shaft,  but  also  extending 
between  them,  may  combine  the  characters  of  both  supra- 
condyloid and  intercondyloid,  thereby  producing  a  T-fract- 
ure  (Figs.  85  and  89). 


FRACTURES   OF    THE    LOWER   EXTREMITY. 


157 


Fig.  8s. 


As  fractures  of  this  part  of  the  bone  are  more  likely  to 
be  produced  by  indirect  violence,  as  falls  upon  the  feet  or 
by  lateral  strains  of  the  leg  or  knee-joint,  there  is  usually 
less  injury  and  consequent  swelling  of  the  soft  parts. 
If  not  involving  the  joint,  such  fractures  show  more  or 
less  overlapping,  the  direction  of  which,  as  is  already  demon- 
strated in  Figs.  83,  84  and  88,  is  determined  by  the  inclina- 
tion of  the  plane  of  fracture.  Overlapping  and  shortening 
are  not  so  marked  as  in  fractures  of  the 
shaft  higher  up.  Reduction  is  often 
easily  accomplished,  and  the  fragments 
once  restored  may  show  little  tendency 
to  become  again  displaced.  The  fractured 
surfaces  being  broad  and  rough  settle  into 
place  and  become  engaged  in  each  other. 
Fixation,  too,  is  perfected  with  greater 
ease  and  less  restraint  than  in  fracture 
up  the  shaft.  On  account  of  these  modi- 
fied conditions,  fracture  at  the  lower  third 
of  the  femur  may  be  a  much  less  serious  injury  than  when 
the  shaft  is  broken  about  its  middle  third.  Involvement 
of  the  knee-joint,  however,  adds  a  complication  which  may 
more  than  offset  these  circumstances,  and  wounding  of  the 
femoral  artery  by  one  of  the  fractured  fragments  is  a  most 
serious,  though  fortunately  very  rare,   complication. 

Supracondyloid  fractures,  if  transverse,  may  readily  be 
confounded  with  epiphyseal  separations  in  subjects  under 
twenty  years  of  age.  The  absence  or  indistinctness  of 
crepitus  will  point  to  the  latter,  and  the  fact  that  separation 


T-fracture  of  the  femur. 


i58 


A    CLINICAL    TREATISE    ON  EKACTURES. 


of  the  lower  epiphysis  is  in  a  plane  slightly  lower  than  the 
common  seat  of  snpracondyloid  fracture  may  suggest  the 
greater  probability  of  one  than  the  other.  In  a  girl  of  six- 
teen years  of  age  whose  knee  had  been  ankylosed  at  a  right 
angle  since  childhood  I  corrected  the  deformity  after  what 
fig.  86.  was   assumed    to    be   an    epi- 

physeal separation;  the  opin- 
ion in  this  case  was  based 
upon  the  faint  crepitus  elic- 
ited, the  close  proximity  of 
the  line  of  separation  to  the 
knee-joint,  and,  finally,  upon 
the  assumption  that  union  of 

Fig.  87. 


Skiagraph  of  external  condyle  of  the  femur. 


Intercondyloid  fracture. 


epiphysis  with  diaphysis  had  been  retarded  by  the  degree 
of  arrest  of  development  observed  in  the  entire  limb  from 
disease  and  disuse. 

Diagnosis. — Fracture    of    the    lower    extremity    of    the 


FRACTURES   OF   THE   LOWER   EXTREMITY.  1 59 

femur,  while  usually  readily  recognized,  is  difficult  to  map 
out  accurately,  particularly  in  fat  subjects.  The  deformity 
of  genu  valgum  belongs  to  fracture  of  the  external  condyle, 
while  that  of  genu  varum  to  that  of  the  internal  condyle, 
but  according  to  the  direction  of  its  plane,  either  deformity 
may  occur  after  supracondyloid  fracture.  In  the  latter 
if  the  plane  of  fracture  is  anteroposteriorly  oblique  the  con- 

FlG.  88. 


Skiagraph  of  fracture  of  the  lower  end  of  the  femur  with  slight  deformity. 

dyles  will  ride  up  in  front  or  behind  (Figs.  84  and  88)  the 
shaft  according  to  the  direction  of  the  obliquity,  whether 
looking  downward  and  forward  or  upward  and  forward.  As 
crepitus  is  usually  very  distinct  and  easily  produced  in  any 
of  these  fractures,  and  as  the  deformity  is  readily  corrected, 
they  are  unlikely  to  be  mistaken  for  any  form  of  disloca- 
tion of  the  knee-joint,  properly  so  called.  That  a  partial 
dislocation  of  the  tibia  occurs  after  fracture  of  either  ex- 
ternal or  internal  condyle  of  the  femur  is  obvious,  but  such 
a  joint-displacement,  depending  as  it  does  upon  the  loss  of 


l6o  A    CLINICAL    TREATISE    ON  FRACTURES. 

opposing  bone  support,  can  only  be  regarded  as  an  incidental 
dislocation. 

Treatment  of  Fractures  of  the  Femur. — The  two 
important  indications  in  the  treatment  of  fracture  of  the 
thigh  are  (i)  to  overcome  shortening,  and  (2)  to  prevent  by 
fixation  not  only  angular  movements,  but  rotary  movements 
as  well. 

In  the  femur,  more  than  in  any  other  bone,  the  tendency 
fig.  89.        to   reproduction  of  the   deformity  by  muscular 

i  action  is  most  marked.  In  no  other  fractures 
are  the  muscles,  which  are  among  the  strongest 
in  the  body,  observed  to  be  thrown  into  such  a 
state  of  spasmodic  contraction  when  their  nat- 
ural support,  the  continuity  of  the  shaft  of  the 
bone,  is  gone.  In  most  other  fractures,  the 
element  of  muscular  contraction  in  causing  de- 
formity has  been,  in  my  opinion,  frequently 
overestimated.  The  muscles  of  the  upper  ex- 
tremity, both  of  the  arm  and  forearm,  are  more 
T-fracture     of    frequently    relaxed    voluntarily   by    the    patient 

the  lower  ex- 
tremity of  the     t°   relieve    pain  than    spasmodically  contracted. 

femur.  ^ot   s0   ftie    powerful    muscles    of    the    thigh. 

Less  perfectly  coordinated  by  volition,  they  are,  after  fract- 
ure, very  irritable  ;  and  not  until  they  yield,  either  through 
the  instrumentality  of  anaesthesia,  the  effect  of  which  is 
temporary,  or  of  traction,  which  wears  them  out  and  the 
effect  of  which  is  permanent,  can  the  overlapping  and  the 
incidental  deformity  be  overcome.  Traction,  if  conveyed 
through  the  leg,  can,  of  course,  influence  only  those  muscles 


FRACTURES    OF   THE   LOWER   EXTREMITY.  l6l 

whose  origin  and  insertion  exist  directly  or  indirectly  be- 
tween points  affected  by  the  loss  of  continuity  of  the  shaft 
of  the  bone.  Muscles,  on  the  other  hand,  whose  origin 
is  at  a  remote  point  above  and  whose  insertion  is  in  the 
upper  fragment  are  not  at  all  affected  by  traction.  In  this 
fact  will  be  found  the  difficulty  in  dealing  with  the  upper 
fragment  in  fractures  of  the  shaft,  particularly  toward  the 
upper  third.  Traction  upon  the  leg  will  fatigue,  relax,  and 
cause  the  flexor  and  extensor  muscles  of  the  thigh  to  yield, 
but  will  exert  no  influence  upon  the  psoas  and  iliacus  in- 
ternus  or  gluteal  muscles.  When,  therefore,  the  deformity 
depends  upon  the  action  of  the  flexor  and  extensor  muscles 
of  the  thigh  the  first  indication  in  the  treatment  is  to 
combat  the  deforming  action  of  these  muscles.  It  is  gen- 
erally recognized  that  in  the  vast  majority  of  cases  this  can 
best  be  done  by  extension  of  the  leg  obtained  by  Buck's 
extension  apparatus.  Fixation  of  the  fragments,  as  it  can- 
not be  carried  out  as  perfectly  as  in  fractures  of  other  bones, 
requires,  in  order  that  it  may  be  sufficiently  complete  to 
insure  union,  the  most  careful  attention.  It  must  be  borne 
in  mind  that  whatever  form  of  treatment  is  employed, 
a  collateral  aid  to  fixation  is  the  careful  attention  to  every 
detail  in  the  management  of  the  patient  which  will  con- 
tribute to  his  comfort.  If  he  is  obliged  to  raise  himself 
on  one  elbow  to  reach  for  something  on  a  table  at  his 
bedside  and  to  take  his  food,  if  his  back  and  buttocks 
are  irritated  by  crumbs  and  folds  of  clothing,  or  if  he  is 
allowed  to  help  himself  in  using  the  bed-pan,  certain  it  is 

that   no   fracture-dressing   will    prevent    movement    of    the 
11 


1 62  A    CLINICAL    TREATISE    OX  FRACTURES. 

fragments  many  times  a  day.  The  mattress  upon  which  the 
patient  lies,  while  necessarily  hard  and  unyielding,  should 
be  made  comfortable  to  his  back,  the  latter  bathed  and  if 
necessary  protected  at  any  point  which  is  found  to  receive 
too  much  pressure.  Though  it  is  almost  impossible  to  avoid 
disturbing  the  fragments  during  the  various  processes  which 
are  performed  about  his  person,  a  great  deal  can  be  done 
to  prevent  such  disturbance  by  skilful  turning  and  lifting 
of  his  pelvis  and  by  drilling  him  to  relax  his  muscles. 

Fractures  of  the  shaft  of  the  femur  may  be  treated 
by  simple  extension,  by  the  application  of  splints,  or  by  a 
combination  of  extension  with  splints.  The  use  of  a  fixed 
dressing  of  plaster-of-Paris,  either  at  the  start  or  later  on 
in  the  course  of  the  treatment,  is  at  times  desirable.  The 
treatment  by  extension  is  that  by  Buck's  extension  appara- 
tus, which  is  applied  in  the  following  manner :  a  strip  of 
resin  or  rubber  adhesive  plaster  two  inches  wide  is  cut  long 
enough  to  extend  from  just  below  the  seat  of  fracture  to  the 
foot  and  back  again  to  the  same  point,  leaving  a  loop  below 
the  foot  six  inches  in  length.  In  this  loop  is  placed  a  block 
three  inches  long,  the  width  of  the  plaster,  and  the  thick- 
ness of  cigar-box  wood.  In  order  to  retain  the  block  firmly 
in  place  and  at  the  same  time  prevent  adhesion  to  the  skin 
below  the  ankle,  a  strip  of  plaster  of  like  width  is  applied 
face  to  face  to  the  lower  portion  of  the  main  strip  and  the 
block.  The  edges  of  the  long  strip  are  nicked  throughout 
their  length  to  the  depth  of  half  an  inch.  Heating  the  free 
ends  of  the  long  strip  over  an  alcohol-lamp,  if  resin  plaster 
is  used,  they  are  applied  on  the  outer  and  inner  aspects  of 


FRACTURES    OF   THE    LOWER   EXTREMITY.  1 63 

the  cleanly  shaven  thigh  and  leg,  the  block  meanwhile 
being  held  accurately  in  a  transverse  position  two  inches 
below  the  sole  of  the  foot.  The  scoring  of  the  edges  per- 
mits the  strips  to  adapt  themselves  neatly  to  the  limb. 
Circular  strips  one  and  a  half  inches  in  width  are  applied 
with  very  moderate  tension  around  the  ankle,  below  the 
knee,  and,  if  the  fracture  is  above  the  lower  third  of  the 
femur,  above  the  knee.  A  neat  bandage  applied  in  the 
form  of  a  spiral  reverse  of  the  lower  extremity  completes 
the  dressing.  After  the  strips  have  become  firmly  attached 
to  the  skin  of  the  leg,  an  extension  weight  to  the  amount 
of  six  or  eight  pounds  is  attached  by  a  cord  to  the  cross- 
piece  of  the  stirrup  and  carried  over  a  pulley  at  the  foot 
of  the  bed.  Counter-extension  may  be  provided  by  elevat- 
ing the  foot  of  the  bed,  and  fixation  aided  by  the  applica- 
tion of  two  long  sand-bags,  the  one  on  the  outer  side 
extending  from  the  axilla  to  the  sole  of  the  foot  and  that 
on  the  inner,   from  the  perineum  to  the  ankle. 

In  fractures  of  the  upper  portion  of  the  shaft,  since  the 
sand- bags  exercise  very  little  influence  on  the  upper  frag- 
ment, and  as  the  latter  shows  usually  a  marked  tendency 
to  forward  displacement,  other  means  are  required  to  adjust 
and  control  it.  This  may  be  done  by  a  nicely  fitted  card- 
board splint,  occupying  the  whole  anterior  surface  of  the 
thigh  and  retained  by  a  snug' bandage.  Should  it  be  found 
impossible  to  get  satisfactory  adjustment  in  this  way,  the 
lower  fragment  may  be  elevated  in  order  to  meet  its  refrac- 
tory fellow  by  the  careful  adjustment  of  a  double-inclined 
plane.     The   latter,   however,  will    often  be  found    to   give 


164  A    CLINICAL    TREATISE    ON  FRACTURES. 

imperfect  fixation,  the  lower  fragment  being  firmly  attached 
to  the  heavy  cumbersome  apparatus,  while  the  upper  frag- 
ment is  much  more  controlled  by  the  patient's  movements 
than  by  the  splint.  A  Smith's  anterior  splint  extending  up 
over  the  abdomen,  where  it  is  retained  by  a  spica  of  the 
groin,  is  intended  to  meet  this  objection  and  may  occa- 
sionally be  employed  to  advantage.  Finally,  particularly  in 
children,  this  troublesome  deformity  may  at  times  best  be 
corrected  by  vertical  suspension.  While  I  have  met  very 
few  cases  of  fracture  of  the  upper  third  of  the  femur  too 
obdurate  to  yield  to  a  carefully  adjusted  cardboard  splint, 
combined  with  extension,  when  such  occur  they  can  usu- 
ally be  successfully  dealt  with  by  one  or  other  of  these 
methods. 

At  times,  when  Buck's  extension  apparatus  fails  suffi- 
ciently to  retain  the  limb  at  rest,  as  when  the  patient  is 
refractory  from  delirium  or  other  cause,  L,iston's  long  splint 
may  be  employed;  it,  by  retaining  the  hip-joint,  further  con- 
trols the  upper  fragment.  In  very  young  children,  in  whom 
there  is  less  tendency  to  overlapping  either  because  the  fract- 
ure is  more  transverse  than  in  adults  or  because  it  is  not 
complete,  very  satisfactory  correction  of  the  bowing  present 
and  good  fixation  of  the  fragments  may  be  obtained  by  a 
nicely  modelled  cardboard  splint,  extending  from  below  the 
knee  to  the  crest  of  the  ilium,  and  retained  by  a  roller 
bandage  beginning  at  this  lowest  point  and  terminating 
in  a  groin  spica.  Great  care  is  necessary  in  young  chil- 
dren to  prevent  excoriation  either  from  the  dressing  or  from 
neglect  of  cleanliness. 


FRACTURES   OF  THE   LOWER  EXTREMITY.  1 65 

Whatever  form  of  treatment  is  decided  upon,  a  general 
standard  of  the  indications  to  be  fulfilled  by  it  must  be 
made.  Absolute  correction  of  overlapping  and  consequent 
shortening  cannot  be  hoped  for.  If  the  latter  is  reduced 
to  three-quarters  of  an  inch,  the  best  result  possible  will 
in  many  cases  be  accomplished.  Tendency  to  angular  dis- 
placement may  have  to  be  combated  until  considerable 
union  has  occurred.  Rotation  of  the  lower  fragment  in- 
ward, or  more  often  outward,  which  allowed  to  continue 
would  result  in  intoeing  or  outtoeing,  should  be  carefully 
watched  for  and  corrected  from  the  start.  The  retaining 
apparatus  is  required  after  union  appears  firm  ;  and  as  the 
time  at  which  it  does  so  is  a  very  variable  one,  it  is  desirable 
to  continue  the  dressing  two  weeks  after  all  apparent  mobil- 
ity has  ceased.  Mobility  having  therefore  ceased  at  the  end 
of  four  to  six  weeks,  the  dressing  is  removed  in  from  six 
to  eight  weeks.  Such  a  course  of  treatment,  while  it  is 
tedious,  is  the  only  safe  one  to  guard  against  recurrence 
of  deformity  or  refracture. 

Treatment  of  Fractures  of  the  Neck  of  the 
Femur. — As  fracture  in  this  locality  occurs  with  so  much 
greater  frequency  in  the  aged,  considerations  relating  to  the 
patient's  general  condition  may  prove  of  equal  or  greater 
importance  than  the  technical  management  of  the  injury. 
Many  subjects,  who  have  previously  enjoyed  good  health, 
are  so  completely  prostrated  by  the  shock  of  the  injury, 
the  confinement  to  bed,  and  perhaps  the  nervous  depression 
following  the  occurrence,  that  they  gradually  sink,  resisting 
all    efforts    at   restoration,  and  die.     Any  special   treatment 


1 66  A    CLINICAL    TREATISE    OX  FRACTURES. 

selected,  therefore,  as  it  cannot  be  persisted  in  if  the 
patient's  general  condition  fails,  must  be  substituted  by 
another  less  confining,   or  at  times  no  treatment  at  all. 

Moderate  extension  by  Buck's  apparatus  to  the  amount 
of  four  or  six  pounds  is  the  usual  routine  treatment. 
Combined  with  it  some  form  of  fixation  of  the  pelvis  and, 
if  possible,  pressure  upon  the  great  trochanter  should  be 
attempted.  A  nicely  applied  binder  about  the  hips,  with 
a  broad  easy  compress  over  the  trochanter,  will  usually 
accomplish  this.  Should  the  patient  not  fret  under  such 
restraint,  it  may  be  continued  for  eight  weeks.  Through- 
out the  course  of  the  treatment  his  general  condition 
requires  close  attention,  and  any  failure  in  strength  is  the 
signal  for  its  discontinuance.  Should  such  a  course  become 
necessary,  the  reasons  for  it  having  been  clearly  explained 
to  the  patient  and  his  people,  the  surgeon  cannot  be  held 
accountable  for  any  untoward  result  of  the  fracture.  Defects 
in  the  result,  even  when  the  management  of  the  case  is  not 
embarrassed  by  the  patient's  general  condition  are,  as  a 
rule,  shortening  to  the  extent  of  about  one  inch,  and  more 
or  less  eversion  of  the  foot.  Other  modes  of  treatment 
looking  to  better  coaptation  and  more  complete  fixation  of 
the  fragments  are  by  Hodgeu's  suspended  splint,  by  the 
application  of  plaster-of-Paris  with  a  pin  inserted  through 
the  dressing  so  as  to  bring  pressure  to  bear  upon  the  tro- 
chanter fSenn),  or  by  the  pressure  of  a  metal  splint, 
secured  by  means  of  a  band,  over  the  trochanter  (Shaffer). 
The  latter  method  seems  to  be  the  most  effectual  means 
by  which  we  can  secure  union  in  old  ununited  fractures,  a 


FRACTURES   OF  THE   LOWER  EXTREMITY.  1 67 

number  of  cures  of  such  cases  by  its  use  having  been 
reported.  Attempts  to  secure  union  in  ununited  fractures 
of  the  upper  extremity  of  the  femur  by  such  operative 
procedures  as  laying  bare  the  fragments  and  uniting  them 
by  ivory  pegs  or  wire  sutures  have  generally  proved  highly 
unsatisfactory. 

Treatment  of  Fractures  of  the  Lower  Extrem- 
ity OF  THE  Femur. — As  the  element  of  shortening  from 
overlapping  of  fragments,  though  much  less  marked  than 
in  fractures  of  the  shaft,  almost  invariably  exists,  exten- 
sion by  Buck's  apparatus  will  be  found  useful  for  a  period 
of  two  or  three  weeks,  or  until  the  broad  fractured  surfaces 
have  been  sufficiently  united  by  provisional  callus  to  pre- 
vent their  overriding  one  another.  Extension  employed 
with  this  object  is  generally  applicable  to  fracture  of  either 
condyle,  fractures  above  the  condyles,  or  comminuted  fract- 
ures of  the  lower  extremity  of  the  bone,  whether  involv- 
ing the  joint  or  not,  because  no  fracture  in  this  locality  is 
likely  to  be  so  transverse  that  its  surfaces  will  butt  accu- 
rately in  position  and  remain  so,  unaided  by  any  offset  to 
muscular  contraction.  As  the  deformity  in  any  direction 
depends  upon  the  direction  of  the  plane  of  fracture  as  well 
as  upon  muscular  contraction,  no  rule  can  be  given  for  its 
correction  except  as  applicable  in  an  individual  case. 
Should  the  lower  fragment  present  anteriorly,  slight  flexion 
of  the  leg  upon  the  thigh  on  a  very  low  double-inclined 
plane  will  usually  correct  the  displacement.  This  may 
easily  be  combined  with  the  extension  apparatus.  If  the 
lower    fragment    be    displaced    posteriorly,    the   posture    of 


1 68  A    CLINICAL    TREATISE    ON  FRACTURES. 

complete  extension  of  the  leg  will  best  reduce  it.  Fract- 
ure of  the  internal  condyle,  producing  the  deformity  of 
genu  varum,  and  of  the  external,  genu  valgum,  may  be 
corrected  by  the  judicious  adjustment  of  the  sand-bags  in 
conjunction  with  extension.  As  already  stated,  it  is  not 
desirable  to  continue  such  treatment  long.  At  the  end  of 
two  or  three  weeks  all  tendency  to  recurrence  of  deformity 
will  usually  be  found  to  have  disappeared.  Plaster-of-Paris 
dressing  will  then  best  take  its  place.  It  should  extend 
from  the  foot  well  up  to  the  great  trochanter  and  peri- 
neum, but  need  seldom  include  the  pelvis.  The  position 
of  the  knee-joint  is  important,  and  is  determined  not  only 
upon  that  position,  whether  of  slight  flexion  or  complete 
extension,  which  has  previously  been  found  best  to  correct 
the  displacement,  but  upon  the  degree  of  ankylosis  which 
it  is  deemed  probable  may  follow.  In  the  former  the  posi- 
tion which  had  been  found  best  to  correct  the  deformity 
should  be  slightly  emphasized,  thus  tending  to  overcorrect 
it,  in  order  to  maintain  good  correction  after  the  dressing, 
drying  out,  has  yielded  somewhat.  In  the  latter,  slight 
flexion  (ten  degrees)  is  the  best  position  that  can  be  assumed 
in  anticipation  of  rigidity.  The  plaster  dressing,  having 
been  retained  from  four  to  six  weeks,  may  be  removed,  and 
not  reapplied  if  union  is  found  satisfactory.  Passive  motion, 
massage,  and  gentle  use  for  a  fortnight  will  best  hasten 
restoration,  after  which  the  patient  may  walk  about  freely 
on  crutches  or  with  a  cane. 


CHAPTER    IV. 
FRACTURES    OF   THE    PELVIS. 

The  pelvis  is  usually  fractured  by  some  crushing  force, 
as  the  falling  of  a  bank  of  earth,  being  caught  in  an  ele- 
vator, or  crushed  between  swinging  bales  of  cotton  and 
a  wall.  In  such  cases  the  ilium  or  the  pubis  most  com- 
monly yields. 

Fractures  of  the  Ilium. — The  ilium  is  a  more  common 
seat  of  fracture  than  any  other  bone  of  the  pelvis,  and  the 
anterior  superior  spinous  process  is  the  portion  of  it  most 
commonly  involved,  although  the  fracture  may  cross  its  body 
in  any  direction  (Figs.  90  and  91).     It  is,  therefore,  fortunate 

Fig.  90. 


Comminuted  fracture  of  the  ilium. 

that  fractures  of  the  ilium  are  the  least  liable  of  all  fractures 
of  the  pelvis  to  damage  bloodvessels,  bladder,  urethra,  or  rec- 
tum. In  many  fractures  of  the  pelvis,  where  the  ilium  is  the 
only  bone  which  can  be  clearly  demonstrated  to  be  fractured, 


169 


170  A    CLINICAL    TREATISE    ON  FRACTURES. 

surprisingly  little  reaction  follows  after  what  appears  to  have 
been  a  very  grave  injury ;  such  cases  often  recover  rapidly 

Fig.  91. 


^ 


Fracture  of  the  ilium. 

and  without  a  drawback  :  indeed,  so  far  as  my  own  experi- 
ence is  concerned,  I  have  seen  numerous  fractures  of 
the  pelvis,  but  very  few  in  which  any  complication  was 
present. 

Fractures  of  the  Pubis. — A  breaking  strain  acting  upon 
the  pubis  in  a  youthful  subject  usually  results  in  a  diastasis 
at  its  symphysis,  while  in  adults  such  forces  may  cause  fract- 
ure either  at  this  point  or  in  the  ramus.  The  close  proxim- 
ity of  the  bladder  and  the  urethra  renders  fractures  of  the 
pubis  serious  if  either  of  these  organs  is  involved  ;  the  blad- 
der, if  torn,  allowing  escape  of  urine  into  either  the  perito- 
neal cavity  or  the  deep  fascia  adjacent,  while  laceration  of 
the  urethra  usually  causes  extravasation  into  the  perineum  or 
scrotum.  Fracture  of  the  pubis  in  very  severe  pelvic  injuries 
is  apt  to  coincide  with  fracture  of  the  ilium,  ischium,  or 
sacrum,  but  particularly  in  youthful  subjects  it  frequently 
exists   without    any    discoverable    yielding   of    other   bones 


FRACTURES    OF   THE   PELVIS.  171 

contributing  to  the  pelvic  cylinder.  It  is  seldom  accom- 
panied by  much  displacement  if  uncomplicated  by  other 
fracture,  and  can  easily  be  recognized  by  forcible  manipu- 
lation of  the  ilia  in  opposite  directions. 

Fractures  of  the  Ischium. — While  fracture  of  the  tu- 
berosities of  the  ischium  may  be  caused  by  falling  upon  the 
buttocks,  and  even  during  labor,  it  is  probably  one  of  the 
rarest  bones  of  the  skeleton  to  be  fractured.  As  a  simple 
injury,  there  may  be  little  displacement,  and  any  readjust- 
ment of  fragments  that  may  prove  necessary  will  be  facili- 
tated by  the  introduction  of  a  finger  into  the  rectum  or  the 
vagina  in  the  female. 

Like  fractures  of  the  pubis,  they  become  serious  in  pro- 
portion to  the  damage  which  has  been  done  to  important 
organs  in  close  proximity. 

Fractures  of  the  Acetabulum. — Fractures  of  the  acetab- 
ulum may  be  caused  by  any  injury  fig.  92. 
which  acting  on  the  trochanter 
major  may  fracture  the  neck  of  the 
femur ;  that  this  socket,  however, 
is  amply  strong  enough  for  even  ex- 
traordinary requirements  is  shown 
by  the  extreme  rarity  of  fracture 
involving  it  and  the  great  frequency 
of  fracture  of  the  neck  of  the  femur. 

It  is  evident    that  Unless    the    rim  of  Fracture  of  the  acetabulum. 

the  acetabulum,  as  in  Fig.  92,  is  so  damaged  as  to  allow  of 
the  escape  of  the  head  of  the  femur,  a  diagnosis  of  the 
injury  would  never  be  reached  with  any  certainty.     Should 


172  A    CLINICAL    TREATISE    ON  FRACTURES. 

crepitus  be  elicited,  it  would  be  simply  crepitus  referred  to 
the  head  of  the  femur,  and  could  not  be  discriminated  from 
fracture  of  the  latter  without  displacement.  Were  it  possi- 
ble that  a  skiagraph  would  indicate  its  presence,  full  infor- 
mation regarding  the  management  of  the  case  would  be 
obtained,  for  not  only  would  the  femur  be  observed  to  be 
intact,  but  the  presence  or  absence  of  any  displacement  of 
its  head  would  be  demonstrated. 

The  TREATMENT  of  fractures  of  the  pelvis  unaccom- 
panied by  visceral  or  other  serious  lesions  may  be  summed 
up  in  the  single  indication,  recumbency  ;  to  this  may,  in 
certain  cases,  be  added  the  steadying  effect  of  large  sand- 
bags to  the  hips,  with  a  firm  bandage  around  the  pelvis,  pro- 
vided no  tendency  to  displacement  of  fragments  is  caused  by 
the  pressuie  it  exerts. 

Blood  in  the  urine  may  depend  upon  laceration  of  the 
urethra  or  of  the  bladder,  or  upon  injury  of  the  kidney. 
When  caused  by  the  two  former,  it  usually  appears  in  clots ; 
when  originating  from  the  latter,  it  is  so  incorporated  with 
the  urine  as  to  give  it  a  dark,  reddish  color.  In  order  to 
ascertain  definitely  which  organ  may  have  been  wounded 
by  the  fracture  or  by  the  severity  of  the  crushing  force 
affecting  also  the  loin,  the  urethra  should  first  be  examined 
by  means  of  a  catheter.  If  there  be  a  tear  of  the  urethra, 
passage  of  the  instrument  will  probably  be  arrested  before 
entering  the  bladder.  If,  on  the  other  hand,  the  instrument 
passes  readily  into  the  bladder  and  allows  urine  mixed  with 
blood-clots  to  escape,  wound  of  the  latter  may  be  assumed. 
In  order  to  determine  whether  the  wound  of  the   bladder 


FRACTURES    OF   THE   PELVIS.  1 73 

has  caused  it  to  leak,  ten  or  twelve  ounces  of  sterile 
water  should  be  injected  and  evacuated.  If  the  portion 
evacuated  is  equal  to  or  greater  than  that  injected,  the 
bladder  is  shown  to  be  probably  competent,  though  valve- 
like penetrating  wounds  of  its  wall  have  occasionally  allowed 
escape  of  urine  either  into  the  peritoneal  cavity  or  into  the 
perineum,  even  though  all  of  a  good  volume  of  water  has, 
after  injection,  been  withdrawn.  If  the  fluid  injected  into 
the  bladder  is  lost  and  fails  to  return,  exploration  of  the 
organ  should  be  made  without  delay  by  laparotomy,  the 
wound  sutured,  and  the  abdominal  cavity  freely  flushed  with 
normal  salt  solution.  If  the  urethra  be  found  lacerated, 
perineal  section  exposing  the  wound  and  allowing  the 
entrance  of  a  sound  into  the  bladder  should  be  made.  This 
section  seldom  need  extend  into  the  bladder.  Microscopic 
examination  will  readily  prove  the  kidney  to  be  the  source 
of  hemorrhage,  and  should  always  be  made  in  doubtful 
cases. 


CHAPTER    V, 


FRACTURES    OF    STERNUM    AND    RIBS. 

FRACTURES  OF  THE  STERNUM. 

Fractures  of  this  bone  are  not  of  very  frequent  occur- 
rence. A  condition  of  diastasis  of  the  manubrium  from 
the  body  of  the  bone  is  occasionally  mistaken  for  fracture, 
and  is  more  common  than  the  latter  in  the  early  years  of 
life. 

The  sternum  may  be  fractured  by  direct  violence  or  by 


Fig.  93. 


muscular  action,  as  in  parturition,  or  by 
vomiting,  though  instances  of  the  latter 
must  be  very  rare.     The  line      fig.  94. 
of  fracture   is   usually   trans- 
verse, though  cases  of  longi- 
tudinal   fracture    have    been 
reported. 

The  most  common  seat  of 
fracture  is  at  the  line  of  union 
of  the  manubrium  with  the 
body  of  the  bone    (Fig.    93), 

Fracture  of  the 

though  the  bone  may  be  frac-     body  of    the 
tured  lower  down,  through  its     sternum. 

body,    as    in    Fig.    94,    or    the    ensiform    cartilage    may   be 

broken  off. 

The    most  serious   feature  of  fracture  of  the  sternum  is 

the   liability    to    coincident   injury  of  the    thoracic  viscera. 

174 


Fracture  of  the  sternum  at 
the  junction  of  the  manu- 
brium with  the  body. 


FRACTURES   OF  STERNUM  AND   RIBS.  IJ$ 

The  extent  to  which  the  latter  will  be  damaged  depends 
largely  upon  the  amount  of  laceration  of  the  posterior  lig- 
ament. If  the  latter  remains  intact,  but  little  injury  is 
likely  to  be  done  to  the  viscera;  but  if  extensively  torn  the 
liability  to  visceral  complications  is  greatly  increased.  The 
lungs  are  the  organs  most  exposed  to  danger  in  fracture 
of  the  sternum,  but  the  heart  has  been  injured,  the  lesion 
in  such  cases  always  producing  a  fatal  result. 

Diagnosis. — Owing  to  the  superficial  position  of  the  bone, 
the  diagnosis  of  fracture  of  the  sternum  does  not,  as  a  rule, 
present  much  difficulty.  Deformity  and  mobility  are  appa- 
rent, and  crepitus  is  generally  readily  elicited.  There  is  con- 
siderable pain,  and  dyspnoea  is  a  fairly  constant  symptom.  If 
the  lung-tissue  has  been  penetrated,  subcutaneous  emphysema 
rapidly  occurs  ;  and  to  this  is  occasionally  added  haemoptysis. 

Treatment. — Reduction  of  the  displacement  is  the  first 
indication  in  the  treatment,  and  very  often  proves  difficult. 
Direct  pressure  on  the  fragments  may  be  aided  by  placing 
some  hard  object  in  the  form  of  a  pad  under  the  back  be- 
tween the  shoulders,  and  then  making  traction  over  it  upon 
the  shoulders  and  neck.  This  manipulation  may  be  rein- 
forced by  instructing  the  patient  to  aid  the  efforts  at  traction 
of  the  surgeon  by  taking  a  full  inspiration  at  the  moment 
the  shoulders  are  drawn  back. 

After  reduction  the  chest  should  be  immobilized  by  the 
application  of  strips  of  adhesive  plaster.  Firm  bony  union 
of  the  fragments  generally  occurs  within  four  weeks  after 
the  injury ;  but  a  few  cases  have  been  reported  in  which  the 
union  was  of  ligamentous  nature. 


176  A    CLINICAL    TREATISE    ON  FRACTURES. 

FRACTURES    OF    THE    RIBS. 

Fractures  of  the  ribs  are  almost  without  exception  pro- 
duced by  direct  violence,  though  in  some  extremely  rare 
instances  by  muscular  action.  When  caused  by  direct  vio- 
lence, as  from  a  fall,  where  the  body  strikes  upon  some 
prominent  object,  as  the  edge  of  a  wall  or  curbstone,  or 
where  the  fracture  is  produced  by  a  blow  from  the  fist,  the 
kick  of  a  horse,  or  even  from  overzealously  performed 
efforts  at  producing  artificial  respiration,  one,  two,  or  at 
most  three  ribs  may  be  broken,  and  while  the  injury  is  a 
painful  one,  it  does  not  cause  those  alarming  general 
symptoms  of  dyspnoea  and  shock  which  occur  after  col- 
lapse of  the  thorax  from  fracture  of  a  number  of  ribs  on 
one,  or  both  sides.  Such  crushes  are  produced  by  the  pas- 
sage of  a  heavy  wheel  over  the  thorax,  by  being  caught  be- 
tween buffers  or  swinging  bales  of  cotton.  For  the  former 
class  of  fractures,  little  or  nothing  is  required  but  manage- 
ment of  the  fracture;  while  in  the  latter  class  of  cases  the 
fracture,  except  as  allowing  the  collapse  of  the  chest,  is  a 
very  unimportant  part  of  the  injury,  fatal  shock,  either  from 
the  interference  with  respiration  alone  or  dyspnoea  combined 
with  intrathoracic  hemorrhage,  constituting  the  elements  of 
the  greatest  urgency. 

A  remarkable  instance  of  fracture  of  the  ribs  from 
muscular  violence  occurred  to  an  acquaintance  of  mine, 
who  was  an  athlete  of  extraordinary  strength,  during  the 
performance  of  a  gymnasium  figure  called  l'the  flag,"  a 
figure  consisting  in  holding  the  body  and  lower  extremities 
out  horizontally  by  the  extended  arms.     The  figure  is  per- 


FRACTURES    OF  STERNUM  AND   RIBS.  \JJ 

formed  by  seizing  two  iron  rings  or  handles  set  in  a  vertical 
post  about  four  and  a  half  feet  apart,  and  carrying  the 
body  straight  out  at  arms'  length.  As  an  enormous  ten- 
sile strain  is  put  upon  the  arm  holding  the  upper  ring,  it 
will  easily  be  seen  that  the  ribs  would  likewise  be  sub- 
jected in  such  an  effort  to  an  inordinate  strain.  One  or  more 
ribs  were  broken,  but,  unfortunately,  the  seat  of  fracture  and 
other  particulars  cannot  be  stated.  The  presence  of  pneu- 
matic support  to  the  chest-wall  during  the  application  of 
exterior  force  is  an  important  factor  in  enabling  the  ribs  to 
resist  pressure  and  blows  to  which  without  such  support  they 
would  readily  yield.  The  heavy  weights  which  acrobats  can 
without  discomfort  allow  to  rest  upon  their  chests  by  holding 
a  full  inspiration  shows  the  resistance  of  the  chest,  when  so 
prepared,  to  enormous  pressure.  The  resistance  to  blows 
upon  the  chest  received  in  sparring,  obtained  by  air  support 
combined  with  muscular  tension,  is  always  taken  advantage 
of  by  the  expert.  Illustrating  the  importance  of  such  pneu- 
matic support  by  its  absence,  I  witnessed  the  autopsy  of  a 
case  of  opium-poisoning  in  which  several  ribs  had  been 
fractured  by  too  energetic  efforts  at  artificial  respiration. 
The  patient's  condition  of  complete  narcosis  deprived  him 
of  all  muscular  as  well  as  respiratory  power  to  resist  press- 
ure, and,  to  the  great  humiliation  of  his  attendants,  though 
the  result  was  probably  not  determined  thereby,  the  ribs 
yielded.  The  middle  and  lower  ribs  from  their  exposed 
position  are  more  liable  to  fracture  than  the  upper.  The 
seat  of  fracture,  while  it  is  more  frequently  anterior  to  the 

angle  of  the  rib,  may  often  be  situated  posterior  to  it,  par- 
12 


178  A    CLINICAL    TREATISE    ON  FRACTURES. 

ticularly  in  crushing  forces.  Even  in  adults  fracture  of  the 
rib  is  probably  often  incomplete.  Accompanying  a  complete 
fracture  of  an  adjoining  rib  such  a  condition  would  in  all 
probability  escape  attention. 

Diagnosis. — Pain  and  crepitus  are  the  principal  signs. 
Pain  on  pressure  over  the  seat  of  suspected  fracture,  which 
in  degree  is  out  of  all  proportion  to  the  pain  of  a  bruise ; 
pain  on  ordinary  or  deep  inspiration  which  can  seldom  be 
localized  with  any  degree  of  accuracy  by  the  patient.  Crep- 
itus and  mobility  can  frequently  be  elicited  by  direct 
palpation,  but  their  absence  in  no  wise  negatives  the  ex- 
istence of  fracture.  Crepitus  may  occasionally  be  de- 
tected by  auscultation,  if  the  patient  can  be  induced  to 
take  a  deep  inspiration.  After  twenty-four  hours  a  local- 
ized traumatic  pleurisy  is  usually  developed,  the  friction 
of  which  is  not  likely  to  be  mistaken  for  bony  crepitus. 
A  valuable  sign  of  fracture  is  obtained  in  many  cases  by 
forcibly  compressing  the  chest  anteroposteriorly,  a  sharp 
impulse  being  given  by  one  hand  applied  to  the  sternum 
while  a  counter-impulse  is  given  by  the  other  hand  at  the 
back.  This  manipulation  will  frequently  produce  pain  at 
the  seat  of  fracture.  Finally,  may  be  mentioned  deform- 
ity, though  as  it  is  so  seldom  present  it  is  probably  the 
least  valuable  of  the  signs  of  fracture.  That  the  ribs  are 
so  often  fractured  without  any  apparent  displacement 
of  the  fragments,  either  overlapping  or  angular,  depends, 
of  course,  upon  their  complete  sheathing,  periosteal,  ten- 
dinous, and  fascial.  Their  extreme  elasticity  in  youth 
renders  fracture  relatively  rare  in  young  subjects  as  com- 


FRACTURES   OF  STERNUM  AND   RIBS.  1 79 

pared  with  its  frequency  after  middle  life,  and,  for  the 
same  reason,  they  are  more  often  the  seat  of  incomplete 
fracture  in  the  young  than  in  the  old. 

The  most  important  complications  met  with  in  fractures 
of  the  ribs  are  (1)  puncture  of  the  lungs,  producing  pneumo- 
thorax, (2)  hemorrhage  from  the  lung  or  from  an  intercostal 
artery,  and  (3)  rarely,  injury  to  the  heart.  Puncture  of  the 
lung  followed  by  pneumothorax  was  well  illustrated  by  a 
case  which  came  under  my  observation  at  the  Pennsylvania 
Hospital.  A  boy,  six  years  old,  was  brought  to  the  hospital 
with  an  injury  of  the  chest  caused  by  the  passage  of  a  cart- 
wheel over  it.  He  suffered  much  shock  and  great  dyspnoea. 
Physical  examination  of  the  chest  revealed  complete  pneu- 
mothorax of  the  left  side.  As  no  fracture  of  a  rib  could  be 
discovered  either  by  palpation  or  by  skiagraph,  the  conclu- 
sion was  reached  that  such  a  fracture  had  occurred  beneath 
the  scapula  and  was  masked  by  it,  and  that  the  point  of 
one  fragment  had  penetrated  the  lung.  His  chest  was  aspir- 
ated twice  for  the  removal  of  air,  but,  as  the  lung-wound 
had  not  closed,  with  only  little  relief.  On  each  occasion 
intrathoracic  pressure  was  so  great  that  not  only  was  the 
heart  displaced  markedly  to  the  right  side,  but  on  removal 
of  the  needle  cellular  emphysema  occurred  so  quickly  that 
localized  pressure  at  the  point  of  puncture  was  required  to 
prevent  the  emphysema  becoming  general.  Later  on,  free 
incision  evacuated  a  large  quantity  of  blood-stained  pus. 
The  boy  recovered  ;  but  three  months  after  the  injury  was 
again  admitted  to  the  hospital,  into  the  medical  ward,  with 
pneumonia   of    the   right   side,    of    which   he   died.      Post- 


l8o  A    CLINICAL    TREATISE    ON  FRACTURES. 

mortem  examination  revealed  green-stick  fractures  of  the 
fifth  and  sixth  ribs,  not,  as  was  supposed,  beneath  the 
scapula,  but  in  the  axillary  line.  Their  character  was 
such,  however,  that  failure  to  detect  them  was  clearly  ac- 
counted for. 

In  some  cases  puncture  of  the  lungs  by  a  broken  fragment 
of  a  rib  is  fortunately  not  followed  by  pneumothorax,  but 
by  cellular  emphysema.  While  the  reason  for  this  cannot 
be  positively  explained,  it  is  probable  that  old  pleuritic 
adhesions,  obliterating  the  pleural  cavity  at  the  seat  of 
fracture,  allow  the  air  to  pass  directly  to  it  and  into  the 
areolar  tissues.  That  perforation  of  the  lung  has  occurred 
in  every  case  of  fracture  of  a  rib  accompanied  by  cellular 
emphysema  is  certain. 

Treatment. — As  nearly  complete  fixation  of  the  frag- 
ments as  possible  is  the  important  element  in  the  treatment, 
for,  there  being  no  displacement,  reduction  is  very  rarely 
required.  As  the  principal  cause  of  movement  at  the  seat 
of  fracture  is  that  produced  by  respiration,  to  restrict  this 
movement  on  the  injured  side  is  the  object  sought.  This 
may  best  be  done  by  strapping  the  chest.  The  area  to  be 
covered  extends  from  the  base  of  the  chest  to  the  axilla,  and 
from  a  point  three  inches  from  the  median  line  on  the  sound 
side  in  front,  to  a  corresponding  point  behind.  Two-inch 
straps  are  used,  and  should  be  applied  thus  :  Anchor  one  end 
of  a  strap  at  the  lowest  point  either  behind  or  in  front.  The 
patient  is  directed  to  breathe  out  as  fully  as  possible,  mean- 
while steadying  himself  with  the  arm  of  the  sound  side.  At 
the  moment  expiration  is  complete  the  strap  is  laid  horizon- 


FRACTURES  OF  STERNUM  AND  RIBS.  151 

tally  with  considerable  force,  its  upper  border  dipping  quite 
deeply  into  the  skin,  in  order  to  prevent  it  from  being  puck- 
ered by  the  lower  border  of  the  next  strap.  The  same  ma- 
noeuvre is  repeated  for  each  successive  strap,  until  about  six 
are  applied,  overlapping  one  another  one-half  their  width. 
The  skin  should  always  be  shaved  before  the  application 
of  the  straps.  This  dressing  should  be  renewed  whenever 
the  straps  become  slack,  and  may  be  continued  for  three 
weeks ;  after  which  the  case  seldom  requires  any  attention. 
As  this  plan  of  treatment  is  very  generally  applicable  to 
all  cases  of  fracture  of  the  ribs  unaccompanied  by  any  com- 
plication, it  is  the  only  one  that  need  be  mentioned.  In 
cases  complicated  by  puncture  of  the  lung  accompanied  by 
cellular  emphysema  the  latter  is  controlled  and  prevented 
from  any  tendency  it  may  have  to  become  general  by  the 
interposition  beneath  the  straps  at  the  point  or  points  of 
fracture,  of  a  compress,  the  size  of  an  English  walnut,  of  a 
piece  of  gauze  rolled  into  a  ball.  In  cases  complicated  with 
pneumothorax,  strapping,  while  not  contraindicated,  may  be 
useless  because  of  the  induced  immobility  of  the  chest  by 
the  pneumothorax  on  the  side  affected.  Should  the  chest- 
wall  incline  to  collapse  from  several  fractures,  strapping  is 
contraindicated,  as  it  would  tend  to  diminish  still  further  the 
intrathoracic  area.  Hemorrhage  from  an  intercostal  artery 
must  indeed  rarely  be  severe  enough  and  persistent  enough 
to  require  radical  means  for  its  arrest.  If  it  should,  how- 
ever, resection  of  the  rib  in  order  to  reach  the  vessel  on 
the  cardiac  side  of  the  hemorrhage  would  become  necessary. 


CHAPTER    VI. 
FRACTURES   OF   THE    SPINE. 

As  the  vertebral  column  may  be  described  as  an  irregu- 
larly shaped  hollow  cylinder  containing  within  its  calibre 
the  spinal  cord,  its  walls  pierced  at  numerous  points  for  the 
passage  of  spinal  nerves,  any  fracture  which  causes,  through 
displacement  of  fragments,  encroachment  upon  this  calibre 
is  liable  to  bruise,  wound,  or  sever  the  cord  or  the  nerves 
given  off  by  it.  Fracture  of  the  spine  is  produced  by  direct 
impact,  by  force  indirectly  communicated,  or  by  violent 
flexion.  Any  portion  of  a  vertebra — the  body,  the  laminse, 
or  the  processes — may  be  fractured;  but  the  essential  element 
of  the  lesion  commonly  spoken  of  as  "fracture  of  the  spine" 
implies  a  fracture  which  has  caused  injury  to  the  cord  or 
the  spinal  nerves.  It  will  be  seen,  therefore,  that  as  the 
spinous  processes  do  not  contribute  to  the  formation  of  the 
bony  tube,  they  may  frequently  be  separated  without  giving 
rise  to  any  general  nervous  symptoms ;  but  when  it  is 
remembered  that  the  force  required  to  fracture  a  spinous 
process  is  great  and  concentrated,  it  will  be  understood 
that  it  is  of  a  kind  well  calculated  to  cause  a  greater  or 
less  degree  of  the  condition,  frequently  occurring  without 
fracture,  known  as  spinal  concussion.  Paralysis  following 
fracture  of  the  spine  is  usually  immediate  and  complete  of 

182 


FRACTURES    OF   THE   SPINE.  1 83 

body  and  extremities,  from  a  plane  level  with  the  seat  of 
fracture  downward.  Deformity  when  it  exists  is  apt  to 
be  anteroposterior,  though  not  infrequently,  where  the 
plane  of  fracture  through  the  body  of  a  vertebra  allows  an 
overlapping  which  diminishes  the  thickness  of  that  body, 
the  only  deformity  discernible  is  a  slight  posterior  angular 
displacement,  producing  prominence  of  a  single  spinous 
process.  Such  deformity  is  a  traumatic  reproduction  of 
that  existing  in  Pott's  disease  through  the  carious  disin- 
tegration of  bodies  of  vertebrae.  If  the  fracture  involve 
the  body  of  a  vertebra,  preternatural  mobility  and  crepitus 
are  absent;  but  if  both  laminae  are  completely  broken 
through,  mobility  of  the  spinous  process  belonging  to  the 
injured  vertebra  may  at  times  be  felt,  and,  occasionally, 
even  crepitus.  In  cases  in  which  no  deformity,  mobility, 
or  crepitus  is  discoverable  the  existence  of  fracture  cannot 
be  demonstrated,  but,  should  the  paralysis  show  no  tendency 
to  prompt  abatement,  it  may  be  fairly  assumed.  The  per- 
sistence of  paralysis,  therefore,  after  an  injury  to  the  spine, 
while  not  conclusive,  is  strong  evidence  of  fracture  ;  but 
if  not  corroborated  by  other  signs  of  the  latter  must  be 
accepted  only  with  reserve.  A  woman  was  admitted  to 
the  Pennsylvania  Hospital,  after  a  fall  from  a  third- 
story  window,  with  complete  paralysis  below  the  neck,  of 
trunk,  upper  and  lower  extremities.  Careful  examination 
of  each  cervical  vertebra,  failing  to  reveal  deformity, 
mobility,  or  crepitus,  excluded  every  local  sign  of  fracture. 
Faint  signs  of  improvement  suggested  that  the  spine  was 
not   fractured,    but    that   the    neck   had   been   subjected    to 


1 84  A    CLINICAL    TREATISE    ON  FRACTURES. 

extreme  flexion  with  more  or  less  laceration  of  ligaments 
and  contusion  of  the  cord — a  sprain  of  the  cervical  spine. 
The  prognosis  that  the  paralysis  would  be  evanescent  was 
verified,  for  she  recovered  in  eight  weeks.  Another  case 
illustrating  paralysis  without  definite  cord  lesion  was  that 
of  a  colored  woman  who  was  admitted  to  the  Pennsyl- 
vania Hospital  with  two  gunshot  injuries  inflicted  by  a 
large  calibred  pistol.  One  ball  traversed  the  elbow-joint  ; 
the  other  penetrated  the  chest,  and  was  removed  from 
beneath  the  skin  posteriorly,  in  a  bone-battered  condition, 
at  the  site  of  about  the  sixth  dorsal  vertebra.  On  admis- 
sion she  had  paralysis  of  the  lower  extremities,  which 
within  twenty-four  hours  was  gone.  In  this  case  it  was 
assumed  that  the  cord  had  probably  received  only  a  severe 
concussion  from  the  impulse  of  the  ball  in  close  proximity 
to  it. 

Fractures  of  the  spine  occur  most  frequently  in  the 
dorsal  region  (Fig.  95);  particularly  is  this  true  when  they 
are  produced  by  force  communicated  indirectly  or  by  ex- 
treme flexion.  That  the  spine  yields  here  at  its  middle 
can  be  best  understood  if,  for  the  moment,  the  spinal 
column  is  compared  to  a  limber  stick,  and  if  the  action 
of  extreme  flexion  is  regarded  as  identical  in  its  effect  with 
force  indirectly  applied  through  the  pelvis  or  lower  extrem- 
ities by  a  fall  from  a  height  upon  the  buttocks  or  feet.  A 
walking-stick  pressed  upon  breaks  approximately  at  its 
middle,  just  as  a  walking-stick  will  break  if  thrust  hard 
enough  against  the  ground;  any  flexible  structure  bends 
before   it   breaks,    and   breaks   at    the   middle  of    its  bend. 


FRACTURES    OF   THE   SPINE.  1 85 

For  this  reason  the  common  seat  of  fracture  will  be  in  the 
dorsal  region  whether  the  injury  results  from  a  crushing 
force  which  overflexes  the  spine  or  a  fall  which  from 
momentum  of  superincumbent  body-weight  also  overflexes 
it.     Falls   upon    the   head    are,   except    hanging,    the    most 


Fig.  95. 


Skiagraph  of  fracture  of  the  spine  in  the  dorsal  region. 

frequent  cause  of  fractures  of  the  cervical  vertebrae.  In 
this  locality,  too,  the  mechanism  may  perhaps  most  often 
be  that  of  overflexion  or  overextension,  though  at  times 
one  of  direct  crushing  strain.  Fractures  of  the  atlas  and 
axis  when  resulting  from  falls  upon  the  head  are  probably 
always  caused  by  force  of  a  crushing  character.  The 
common  lesion  resulting  from  hanging,  however — fracture 
of  the  odontoid  process  of  the  axis,   accompanied  by  dislo- 


1 86  A    CLINICAL    TREATISE    ON  FRACTURES. 

cation  of  the  atlas  from  the  latter — is  produced  by  over- 
extension. 

Fractures  of  the  spine  caused  by  force  directly  applied 
occur  at  the  point  of  impact.  The  causes  of  such  fract- 
ures are  falls,   blows,   and  gunshot  injuries. 

Symptoms. — Fractures  of  the  spine  at  different  localities 
possess  many  signs  in  common,  and  yet  they  differ  widely 
according  to  the  nerve-functions  disturbed  or  destroyed  at 
and  below  the  damaged  point  of  the  cord.  There  is  paral- 
ysis, immediate  and  complete,  of  the  trunk  and  extremi- 
ties, from  a  plane,  often  well  defined,  level  with  the  seat 
of  fracture;  there  is  retention  of  urine,  succeeded  in  a  few 
hours  by  permanent  incontinence,  accompanied  also  by 
incontinence  of  the  rectum  ;  there  are  disturbances  of  the 
vasomotor  system  affecting  the  bloodvessels  and  causing 
trophic  changes  in  the  integument  which  markedly  predis- 
pose it  to  necrosis  ;  there  may  be  temperature-changes, 
deviations  from  the  normal,  either  above  or  below.  Also 
there  may  be  sensory  phenomena,  more  or  less  marked, 
manifested  by  girdle-pains  similar  to  those  of  locomotor 
ataxia,  lancinating  about  the  trunk;  and  various  referred 
sensations  over  the  paralyzed  area,  such  as  formication  and 
flushes  of  heat  and  cold.  Gastric  crises  may  occur.  Pria- 
pism is  frequently  observed.  Accompanying  these  symp- 
toms, if  the  case  does  not  tend  to  a  rapidly  fatal  issue,  there 
are  gradual  emaciation  and  general  impairment  of  nutri- 
tion ;  and,  finally,  the  mental  state  may  be  placid  and 
resigned,   or  nervous,   restless,   and  emotional. 

Paralysis   produced   by  fracture  of   the   spine   is  usually 


FRACTURES    OF   THE   SPINE.  1 87 

complete  of  both  motion  and  sensation,  the  line  of  de- 
marcation of  the  latter  being  frequently  clearly  denned. 
Its  effect  upon  the  soft  tissues,  is  principally  manifested 
by  their  tendency  to  become  necrotic  when  subjected  to 
pressure.  In  spite  of  every  precaution  to  equalize  the 
pressure,  the  integument  over  the  sacrum,  and  even  at  the 
heels,  breaks  down  and  causes  most  intractable  bedsores. 
The  paralyzed  extremities  do  not  waste  rapidly,  as  a  rule; 
but  present  a  doughy,  flabby  appearance.  Owing  to  vaso- 
motor defect,  cutaneous  circulation  may  be  somewhat  con- 
gested, and  give  a  flushed  appearance  and  at  times  local 
increase  of  temperature  to  the  surface.  The  bowels  and 
bladder  almost  immediately  become  entirely  incontinent, 
and  their  contents  voided  involuntarily. 

If  the  fracture  occurs  even  as  low  down  as  the  dorso- 
lumbar  region,  there  is  often,  in  addition  to  the  symp- 
toms of  general  paralysis  already  enumerated,  interference 
with  respiration,  due  to  the  muscular  relaxation  of  the 
abdominal  parietes.  Ascending  the  spine,  the  gravity  of 
the  injury  increases  as  the  function  of  the  cord  is  cut  off 
at  a  higher  level,  until  the  second  dorsal  vertebra  is 
reached.  A  fracture  occurring  between  this  point  and  the 
third  cervical  vertebra  (cervico-dorsal  region)  is  likely, 
through  involvement  of  the  brachial  plexus,  long  thoracic, 
or  phrenic  nerve,  to  embarrass  respiration,  or  in  the  case 
of  the  latter  fatally  to  arrest  it.  Fractures  of  the  atlas  and 
axis  are  usually  immediately  fatal  through  the  almost 
inevitable  injury  to  the  medulla  accompanying  them. 

The  above  mentioned  symptoms,  occurring  with  greater 


1 88  A    CLINICAL    TREATISE    OX  FRACTURES. 

or  less  severity,  may  be  consistent  with  life,  and  tend  to 
shorten  it  only  as  they  torment  and  exhaust  the  patient. 
The  prognosis  regarding  recovery  is  most  unfavorable, 
while  that  regarding  life  is  extremely  uncertain.  It  may 
be  generally  stated,  however,  that  many  victims  of  fract- 
ure of  the  spine,  having  survived  the  acute  effects  of  the 
injury,  if  their  environment  and  nursing  are  of  the  best, 
survive  two  or  more  years.  To  what  extent  operation  may 
be  looked  to  to  modify  this  gloomy  prospect  will  be  con- 
sidered in  the  treatment.  Not  always  is  the  termination 
so  unfavorable  as  this.  Recovery  with  more  or  less  per- 
fect restoration  to  health  occasionally  occurs  after  fracture 
with  paralysis  at  any  portion  of  the  spine;  and  besides 
there  may  be  mentioned  a  group  of  cases,  occupying  as  it 
were  a  middle  ground,  which,  although  their  paralysis 
lasts,  recover  their  health,  and  in  their  upper  extremities 
strength  to  such  an  extent  that  with  certain  artificial  aids 
they  can  not  only  help  themselves  in  many  ways,  but  can 
even  get  about.  A  most  generally  useful  appliance  for  these 
cases  is  the  ordinary  wheel-chair  fitted  with  adjustable 
crutches. 

Fractures  of  the  Spinous  Processes. — Fracture  of  the 
spinous  process  of  a  vertebra  is  caused  usually  by  direct 
violence;  and  while  any  vertebra  may  suffer,  the  upper  dorsal 
and  lower  cervical,  through  the  greater  prominence  of  their 
spinous  processes,  are  more  likely  to  yield  from  the  violence 
of  a  direct  blow  than  are  the  processes  of  vertebrae  lower 
down.  They  may  well  be  described  as  the  only  fractures 
of  a  vertebra  which  can  be  clearlv  demonstrated  by  palpa- 


FRACTURES   OF   THE   SPINE.  1 89 

tion,  and  the  only  fractures  which  are  liable  to  occur  with- 
out coincident  injury  to  the  cord  or  spinal  nerves.  Their 
importance  is  so  slight  as  compared  with  other  fractures 
of  the  spine  that  they  hardly  deserve  to  be  classified  as 
such.  The  symptoms  to  be  observed  are  pain  and  tender- 
ness, contusion  of  the  integument  from  impact  of  a  more 
or  less  sharp  body,  with  or  without  signs  of  concussion  of 
the  cord.  On  palpation  the  fractured  process  when  dis- 
covered will  be  found  freely  movable,  but  not  displaced. 
Slight  crepitus  may  be  felt  if  the  process  has  been  com- 
pletely detached. 

In  a  case  of  very  serious  depressed  fracture  of  the  skull 
which  I  had  occasion  to  trephine  at  the  Episcopal  Hospital 
there  was  a  fracture  of  the  spinous  process  of  the  eleventh 
dorsal  vertebra.  It  could  be  readily  detected  on  palpation  as 
abnormally  mobile,  though  it  was  not  at  all  displaced, 
and  its  existence  offered  no  complication  whatever  to  the 
patient's  convalescence  from  the  very  serious  head  injury. 
As  there  is  usually  no  appreciable  displacement  of  a  fract- 
ured process,  no  reduction  is  required  ;  and  rest  in  bed  to 
guard  against  any  concomitant  concussion  of  the  cord 
from  a  crushing  blow  in  such  close  proximity  to  it  is  all 
that  is  necessary.  The  union  of  such  fractures  may  be  by 
bone  or  fibrous  tissue,  but  which  is  the  more  common  result 
cannot,  because  of  insufficient  data,  be  stated. 

Fractures  of  the  I/aminse.— A  fracture  involving  one 
or  both  laminae  of  a  vertebra  can  hardly  occur  without 
injury  to  the  cord.  If  the  laminae  on  both  sides  of  the 
vertebra    are    broken,    a    degree    of    displacement    of   bone, 


I90  A    CLINICAL    TREATISE    OX  FRACTURES. 

as  is  shown  in  Fig.  96,  must  almost  inevitably  occur 
which,  by  encroachment  upon  the  spinal 
canal,  will  bruise,  compress,  or  sever  the 
cord.  If  the  displaced  fragment  spring 
immediately  back  into  its  normal  position, 
whatever  damage  to  the  cord  was  done  re- 
mains, but  no  continued  pressure  exists,  and 
according  to  the  extent  of  this  damage 
Fracture  of  verte-  will  the  cord  recover  or  its  functions  be 
brai  lammas.  irreparably  lost.  Fracture  of  the  laminae 
occurs  most  frequently  in  the  cervical  vertebrae,  because 
of  the  peculiar  arrangement  of  the  spinous  processes  in 
this  region,  and  because  the  neck  is  particularly  vulner- 
able to  the  character  of  injuries  most  liable  to  cause  their 
fracture.  The  fracture  may  be  caused  by  either  a  blow  on 
the  top  of  the  head,  as  in  a  fall,  or  by  diving  in  shallow 
water,  or  from  a  blow  on  the  forehead,  as  in  passing  beneath 
a  bridge  on  horseback  or  on  cartop.  The  effect  of  force 
applied  bv  either  of  these  methods  is  to  overextend  this 
least  supported  part  of  the  column.  The  spinous  processes 
are  so  pressed  upon  at  their  tips  that  the  laminae  yield 
through  the  lever-like  force  exerted  upon  them  by  the 
latter.  But  this  is  by  no  means  always  the  mechanism, 
as  the  neck  may  be  bent  in  some  other  direction  (forward 
or  laterally),  or  may  be  thrust  directly  in  the  line  of  its 
axis,  so  that  the  force  producing  the  fracture  is  a  crushing 
one,  or  depends  upon  these  two  elements  acting  in  com- 
bination with  either  the  weight  or  with  the  resistance  of 
the  body.     A  lesion   so   profound  may  cause  instant  death 


FRACTURES    OF   THE   SPINE.  1 9 1 

if  the  displacement  of  fragments  has  been  marked,  or  if 
the  line  of  fracture  have  implicated  the  phrenic  nerve. 
If  death  is  not  instantaneous,  attention  is  drawn  to  the 
probable  lesion  by  the  sudden  paralysis  of  the  entire  trunk 
and  all  the  extremities.  Shock,  while  present,  may  be 
only  moderate  and  not  of  a  degree  proportionate  to  the 
immense  gravity  of  the  injury.  Occurring  at  other  points 
in  the  spine,  fractures  of  the  laminae  are  accompanied  by 
no  characteristic  signs  which  can  with  any  certainty  be 
relied  upon  to  distinguish  them  from  fractures  of  the  body 
alone,  or  in  combination  with  them.  None  of  the  general 
symptoms  vary;  and  locally,  though  it  may  be  possible  to 
detect  mobility  or  deformity,  which  points  to  fracture  of 
this  portion  of  a  vertebra,  exploration  by  palpation  is  too 
much  masked  by  the  tissues  imbedding  the  spine  to  permit 
of  anything  like  a  satisfactory  demonstration.  Operative 
exploration,  therefore,  as  a  step  preliminary  to  operative 
procedure  may  be  considered. 

Fractures  of  the  Body  of  a  Vertebra. — Fracture  of 
the  body  of  a  vertebra  is  usually  caused  either  by  force  com- 
municated through  the  length  of  the  spine,  as  in  falling  from 
a  height  and  alighting  upon  the  feet  or  buttocks;  or  by  a 
crushing  force,  as  the  falling  of  a  bank  of  earth,  which  pro- 
duces excessive  spinal  flexion.  The  deformity  resulting  from 
such  a  fracture  depends  upon  the  sidelong  displacement  in  the 
direction  of  obliquity  of  the  plane  of  fracture,  with  conse- 
quent diminution  in  the  thickness  of  the  body  of  the  vertebra 
involved.  The  element  of  sidelong  or  lateral  displacement 
encroaches  upon  the  spinal  canal  more  or  less  according  to  its 


192  A    CLINICAL    TREATISE    ON  FRACTURES. 

degree ;  while  the  resulting  diminution  in  the  thickness  of 
the  body  of  the  vertebra  produces  posterior  angular  deformity 
opposite  the  seat  of  fracture  through  the  shortening  of  the 
anterior  pillar  of  the  column,  exactly  as  the  hump  is  pro- 
duced in  Pott's  disease  by  the  carious  disintegration  and  con- 
sequent loss  of  support  of  the  body  of  the  vertebra.  The 
change  in  contour  may  consist,  therefore,  in  undue  promi- 
nence of  the  spinous  process  of  the  damaged  vertebra. 
Should  the  fracture  of  the  body  involve  the  transverse  proc- 
esses or  their  articulating  surfaces,  a  tendency  to  rotary  dislo- 
cation may  appreciably  alter  the  line  of  the  spinous  processes 
in  a  direction  determined  by  the  displacement ;  while  if  the 
tendency  be  to  partial  anteroposterior  dislocation  the  level 
of  this  line  is  affected.  Lateral  displacement  deviates  it 
slightly  to  one  side  or  the  other.  The  general  symptoms 
vary,  as  in  fractures  of  the  laminae,  according  to  the  degree 
of  displacement  and  encroachment  upon  the  calibre  of  the 
canal,  and  the  region  of  the  spine  involved. 

To  sum  up  the  general  conditions  regarding  fractures 
of  the  vertebrae,  it  may  be  stated  that  there  is  the  fracture 
of  the  spinous  process,  which  may  frequently  be  clearly 
demonstrated,  but  which  produces  no  paralysis  and  requires 
no  special  treatment;  there  is  the  fracture  through  one  or 
both  laminae,  which  may  at  times  give  preternatural  mobility 
of  the  corresponding  spinous  process,  and  which  is  almost 
invariably  accompanied  by  paralysis;  and  there  is  the 
fracture  through  the  body  of  the  vertebra,  which,  by 
diminishing    the    thickness    of    the    latter    or    by   causing 


FRACTURES   OF   THE   SPINE.  1 93 

lateral  or  anteroposterior  displacement,  may  produce  angu- 
lar deformity  or  oblique  deviation  in  the  line  of  the  spinous 
processes,  accompanying  which  there  is  no  preternatural 
mobility  or  crepitus.  From  a  clinical  point  of  view,  how- 
ever, it  is  almost  vain  to  dwell  upon  any  symptoms  except 
the  paralysis,  which  can  be  clearly  demonstrated  as  char- 
acteristic of  fracture  of  any  portion  of  a  vertebra;  for  not 
only  may  the  lesion  involve  different  parts  of  one  or  more 
vertebrae,  with  or  without  comminution,  but  often  the  par- 
ticular fracture  responsible  for  the  paralysis  exists  without 
furnishing  a  single  diagnostic  sign.  Fractures  of  the  spine 
produced  by  indirect  violence  or  forced  flexion  of  its  whole 
length  occur  more  frequently  in  the  lower  dorsal  region; 
while  direct  blows,  of  course,  are  likely  to  cause  fracture 
at  the  point  of  impact.  The  higher  up  the  spinal  column 
the  fracture  occurs,  assuming  the  extent  of  the  injury  to 
the  cord  to  be  equal,  the  more  unfavorable  is  the  prognosis. 

Treatment. — The  treatment  of  fracture  of  the  spine 
may  very  properly  be  divided  into  two  distinct  plans,  pal- 
liative and  operative.  Under  palliative  treatment  may  be 
included  gradual  and  continual  extension,  and  forcible 
extension  with  attempts  at  times  at  forcible  reduction  of 
patent  deformity.  Gradual  and  continual  extension  may 
conveniently  be  employed  by  applying  an  extension  appa- 
ratus (Buck's)  to  each  leg.  To  these  a  weight  of  from 
eight  to  twelve  pounds  is  added,  while  counter-extension 
is  obtained  either  by  inclining  the  bedstead  by  elevation 
of    its    foot     four    inches,    or    by    carefully    padded    rings 

13 


194  A    CLINICAL    TREATISE    OX  FRACTURES. 

attached  to  its  head,  through  which  the  arms  are  thrust 
to  the  axillae  and  supported  as  if  on  crutches.  When 
the  latter  are  used  it  is  necessary  to  give  the  patient 
periods  of  rest  from  the  fatigue  which  their  incessant  em- 
ployment causes.  A  quarter  of  an  hour  four  or  five  times 
a  day  may  be  sufficient.  Throughout  the  employment 
of  such  extension  the  greatest  attention  must  be  paid 
to  every  part  of  the  integument  involved  in  the  paralyzed 
area,  in  order  to  avoid  if  possible  the  formation  of  bed- 
sores. The  back,  of  course,  is  the  most  difficult  part  to 
keep  sound.  The  bedding  must  be  kept  dry  and  clean, 
which  is  no  easy  task  with  paralyzed  viscera.  The  crease 
of  a  sheet  or  of  padding  if  allowed  to  remain  a  few  hours 
may  be  the  beginning  of  a  sore.  The  integument  over  the 
sacrum  and  over  the  pelvis  generally,  receiving  more 
pressure  through  the  prominence  of  the  bones  beneath  it, 
requires  the  greatest  attention.  Large  ringed  pads  fre- 
quently changed  and  the  integument  carefully  bathed  many 
times  a  day  with  alcohol  will  probably  give  the  best  results. 
Any  red  point  must  immediately  be  relieved  of  all  pressure 
until  it  pales  again,  for  otherwise  in  twenty-four  hours  it 
will  be  a  sore.  I  have  frequently  kept  the  back  sound  by 
changing  the  position  of  the  patient  once  in  three  or  four 
hours  from  the  right  side  to  the  left  side  and  then  to  the 
back,  alternating  in  this  way  throughout  the  day.  This 
change  in  decubitus  is  sometimes  intolerable  to  the  patient; 
but  when  it  can  be  borne  it  is  of  great  use.  Equable  dis- 
tribution of  pressure  may  be  obtained  through  a  water-  or 
air-mattress.      At  times  it  will  be  found  to  be  most  efficient 


FRACTURES   OF   THE   SPINE.  195 

in  keeping  the  back  sound.  An  objection  to  it,  however, 
is  that  it  may  be  relied  upon  too  much  to  lessen  the  labor- 
ious task  of  frequent  inspection,  bathing,  and  changing  of 
pads,  etc.,  for  this  is  necessary  even  with  its  use.  If  an 
extension  apparatus  is  applied  to  the  lower  extremities,  the 
pulleys  at  the  foot  of  the  bed  must  be  elevated  in  order 
to  convey  the  line  of  traction  in  a  direction  which  will  pre- 
vent undue  pressure  of  the  heels  on  the  mattress. 

Fixation  by  a  plaster  jacket  would  seem  to  be  indicated 
in  cases  characterized  by  unusual  mobility  at  the  seat  of 
fracture.      It  should  be  applied  during  spinal  extension. 

Forcible  extension  with  at  times  an  attempt  at  reduc- 
tion must  invariably  be  performed  under  ansesthetization. 
Manual  extension  exerted  by  four  assistants  upon  the  lower 
extremities,  with  the  usual  sheet-hitches  at  the  knee  or 
ankle,  will  furnish  as  much  force  as  can  be  prudently 
employed.  Counter-extension  upon  the  chest  with  a  sheet 
looped  from  the  back  beneath  the  axillae  and  attached  above 
should  be  supplemented,  if  there  are  enough  assistants  at 
hand,  by  manual  support  of  the  shoulders  and  arms,  as  the 
required  counter-extension  applied  wholly  to  the  chest  is 
liable  to  interfere  too  much  with  respiration.  At  the  word 
from  the  surgeon,  the  assistants  apply  their  forcible  exten- 
sion to  the  lower  extremities,  the  surgeon  meanwhile 
placing  his  fingers  over  the  spine  at  the  seat  of  injury  in 
order  to  perceive  any  change  in  form  which  may  result. 
It  is  evident  that  forcible  extension  applied  in  this  way 
can  only  hope  to  effect  permanent  reduction  by  the  frag- 
ments  remaining   restored   of  themselves,    for   if   they  slip 


196  A    CLINICAL    TREATISE    ON  FRACTURES. 

immediately  out  of  position  nothing  is  accomplished.  The 
manoeuvre  of  forcible  extension,  while  it  may  do  no  good, 
runs  small  risk  of  doing  any  harm,  except  as  applied  to  the 
fractures  of  the  cervical  vertebrae,  where  the  danger  of 
causing  sudden  death  should  be  clearly  explained  to  the 
patient  and  his  friends,   before  it  is  undertaken. 

Operative  treatment  consists  in  exploring  by  incision  and 
dissection  the  seat  of  fracture,  and  either  removing  with 
forceps  any  comminuted  fragments  of  bone  which  may  be 
found  to  be  pressing  upon  the  cord,  penetrating  its  mem- 
brane or  in  any  way  encroaching  upon  the  lumen  of  the 

fig.  97. 


Author's  spinal  ronguer  forceps. 

spinal  canal ;  or  performing  formal  laminectomy.  After 
exposing  the  vertebra,  should  both  laminae  prove  to  be 
fractured,  the  arch  may  easily  be  removed  by  seizing  and 
making  traction  upon  the  spinous  process  with  heavy  for- 
ceps and  dividing  with  a  scalpel  its  ligamentous  and  tendi- 
nous attachments.  The  removal  of  the  arches  of  one  or 
more  vertebrae  by  laminectomy  will  at  times  give  space  and 
thereby  relieve  pressure  upon  the  cord,  which  has  been 
caused  by  displacement  of  fragments  from  a  fracture  even 
of  the  anterior  portion  of  the  column.  The  shock  inci- 
dent  to    such   an    operation    is    not    necessarily   great,    the 


FRACTURES    OF   THE   SPINE. 


I97 


Fig.  98. 


principal  danger  likely  to  be  encountered  being  the  use  of 
the  anaesthetic  required  for  its  performance.  This  danger 
arises  at  times  from  the  condition  of  continued  shock  often 
present,  or  from  the  prone  position  assumed  when  there  is 
already  embarrassment  of  respiration  through  paralysis 
of  the  abdominal  muscles.  The  operation  of  itself  is  not 
very  formidable.  With  the  spinal  ronguer  forceps  shown 
in  Fig.  97,  the  six  pairs  of  laminae  were  for  the  pur- 
pose of  experiment  divided  and  removed  in  ten  minutes 
on  the  cadaver,  as  illustrated  in  Fig.  98.  Having  cleared 
away  the  muscular  and  tendinous  attach- 
ments overlying  the  laminse,  the  forceps,  in- 
sinuated at  a  joint,  are  made  to  cut  from 
below  upwards  in  a  line  situated  midway 
between  the  bases  of  the  transverse  and 
spinous  processes.  After  section  of  the  lam- 
inae on  both  sides,  the  appropriate  spinous 
process  is  seized  with  heavy  toothed  forceps 
and  sufficient  traction  applied  to  make  tense 
any  remaining  tendinous  or  ligamentous 
fibres  which  may  require  division  with  a  specimen 
scalpel.  On  removal  of  the  arch  of  one 
vertebra,  the  indications  for  the  removal  of 
the  one  immediately  adjacent  to  it  must  be  determined  by 
the  requirements  of  the  conditions  found.  If  the  cord 
bulges  and  is  observed  to  be  at  all  nipped  above  or  below, 
further  space  must  be  given  and  the  arch  of  another  ver- 
tebra excised.  Hemorrhage  is  usually  easily  controlled. 
The  question  regarding  the  appropriate  method  of  pro- 


experimental 

laminectomy. 


I98  A    CLINICAL    TREATISE    OX  FRACTURES. 

cedure  which  should  be  adopted  in  any  recent  fracture  of 
the  spine  is  a  very  grave  one,  and,  unfortunately,  cannot 
be  answered  as  definitely  and  distinctly  as  its  importance 
would  demand.  The  whole  subject  of  operation  is  as  yet 
in  a  transition  state,  to  be  either  indorsed  or  negatived 
with  further  experience.  In  favor  of  operation  are :  (a) 
the  chance  which  it  affords  of  removing  a  fragment  of 
bone  which  has  been  so  displaced  that  it  presses  upon 
the  cord  to  an  extent  not  to  destroy  it  irreparably,  but 
which  if  allowed  to  remain  will  inevitably  do  so;  (b)  the 
opportunity  offered  of  relieving  cord-pressure  produced  by 
encroachment  of  displaced  fragments  of  bone  anteriorly, 
by  giving  space  posteriorly  through  laminectomy;  (c)  the 
relief,  also  by  laminectomy,  of  pressure  from  hemorrhage ; 
(d)  the  hopelessness  of  obtaining,  in  almost  every  case,  any 
amelioration  of  symptoms  or  an  arrest  of  the  direful  conse- 
quences of  the  injury  by  any  palliative  measures. 

Against  operation  are:  (a)  the  risk  at  times  of  using  an 
anaesthetic,  owing  to  the  patient's  general  condition,  or  bad 
respiration  ;  (b)  the  complication  of  a  deep  wound  situated 
in  the  worst  possible  place  for  proper  management  and  in 
tissues  which  not  only  will  show  no  disposition  to  heal, 
but  will  probably  slough,  and  may  cause  septic  infection 
that  will,  under  the  conditions,  prove  almost  surely  fatal ; 
and  (c)  the  fact  that  operation,  while  adding  these  draw- 
backs to  a  case  already  most  difficult  of  management,  ac- 
complishes in  the  great  majority  of  cases  little,  and  often 
nothing.  As  it  is  extremely  desirable  that  even  scanty 
data  gained  by  experience    should    be   set  forth  as  fully  as 


FRACTURES   OF  THE  SPINE.  1 99 

possible,  it  may  be  stated  that  in  any  suspected  case  of 
fracture  of  the  spine  accompanied  by  paralysis,  in  which 
within  forty-eight  hours  the  paralysis  shows  a  tendency 
to  slight  improvement,  and  in  which  no  displacement  in 
the  line  of  the  spinous  processes  can  be  detected,  operation 
should  at  least  be  delayed. 

In  cases  where  complete  paralysis  persists  and  deformity 
is  observed,  forcible  extension  under  an  anaesthetic,  if  the 
patient's  general  condition  permits,  may  be  applied.  Should 
this  fail  to  correct  the  displacement,  operation,  if  ever  to  be 
performed,  had  best  be  done  at  once.  If  any  lesson  is  to 
be  learned  from  the  operations  which  have  been  done,  it  is 
that  delay  of  weeks  or  months  has  removed  from  the  case 
the  only  chance  it  had  of  success,  by  allowing  conditions 
which  promptly  removed  would  possibly  have  terminated 
in  resolution,  to  cause,  through  persistent  pressure,  degen- 
eration of  the  cord.  The  very  important  questions  of  the 
earliest  moment  at  which  operation  should  be  performed, 
if  considered  at  all,  and  the  latest  period  it  may  be  hoped 
to  be  of  benefit,  depend  upon  the  special  peculiarities  of  every 
individual  case,  peculiarities  which  become  manifest  only 
upon  exploration.  The  doubt  sure  to  hang  over  every  case 
allowed  to  remain  unexplored  is  whether  it  may  not  be  one 
which  could  be  relieved  by  operation.  If  operation  is  to 
be  performed,  it  should  not  be  delayed  unnecessarily — that 
is,  beyond  the  requirements  of  the  patient's  general  condi- 
tion, and  after  reasonable  prospect  of  improvement  and 
ultimate  recovery  of  function  in  the  cord  has  been  aban- 
doned.     If    by    forcible   extension    it    is    found   possible   to 


200  A    CLINICAL    TREATISE    ON  FRACTURES. 

reduce  the  displacement,  even  incompletely,  that  much  may 
be  felt  to  have  been  accomplished,  and  the  effect  noted 
for  a  period  of  a  week  before  deciding  upon  laminectomy. 
In  reaching  a  decision  whether  or  not  to  operate,  a 
careful  study  of  the  behavior  of  the  paralysis  is  a  more 
useful  guide  than  are  the  observations  of  its  primary  char- 
acter. Its  behavior  or  progress,  should  it  be,  as  already 
pointed  out,  towards  abatement,  furnishes  definite  proof  of 
partial  restoration  of  cord  function,  which  could  not  occur 
with  either  complete  destructive  lesion  or  complete  arrest 
of  function  occasioned  by  pressure  of  bone.  Its  character, 
partial  or  complete,  denoted  by  the  degree  of  anaesthesia 
and  the  preservation  or  obliteration  of  the  superficial  and 
deep  reflexes,  although  indicating  clearly  enough  the  extent 
of  arrest  of  cord  function,  does  not  reveal  whether  such 
arrest  is  produced  by  complete  destruction  of  the  cord, 
which  is  irremediable,  or  by  pressure  upon  it  of  displaced 
fragments  of  bone,  which  may  be  relieved  by  their  removal. 

Fractures  of  the  sacrum  and  coccyx  may  be  mentioned 
along  with  fractures  of  the  spine.  They  are  both  very  rare. 
Fractures  of  the  sacrum  are  amenable  to  the  same  general 
management  as  are  fractures  of  the  vertebrae.  Fracture  of 
the  coccyx  can  occur  only  after  coossification  of  the  bones 
composing  it.  Any  deformity  present  may  be  reduced 
through  the  rectum.  Perfect  rest  and  the  use  of  anodynes 
will  best  guard  against  the  only  serious  consequence  of 
the  injury — coccydynia. 


CHAPTER    VII. 

FRACTURES    OF    THE    SKULL. 

The  skull  from  a  structural  point  of  view  is  somewhat 
anomalous.  So  far  as  approximately  spherical  form  is 
concerned,  its  double  plating  of  compact  substance  with 
an  intervening  layer  of  diploic  or  cancellated  material,  its 
thickened  protuberances  at  salient  points,  the  interlocking 
by  suture  of  the  various  bones  composing  it,  all  combine 
to  give  it  the  maximum  resistance  to  external  violence, 
and  make  it,  for  its  weight,  an  ideal  bone-case.  Its  struct- 
ural defect  consists  chiefly  in  the  lack  of  uniformity  of  its 
thickness  in  different  parts,  which  renders  the  weaker  por- 
tions peculiarly  vulnerable  to  certain  vibratory  forces.  Its 
thickness  varies  in  different  races  and  individuals,  and  in 
like  proportion  does  its  resistance  to  applied  forces. 

The  surgical   importance   of  fracture   of  the   skull,   as  it 

depends   principally    upon    the    fact    that    the    latter   is    the 

brain-case,   subordinates    the    lesion  to   the  more  important 

injury  which  may  be  done  to  the  brain,  either  directly  by 

the  fracture  or  incidentally  by  the  force  producing  it.     A 

displaced    fragment    of    fractured    skull    may   press    upon, 

bruise,   or  wound  the  brain;  but  force  applied  to  the  skull 

also    is  capable,   without  causing   any  fracture,   of  bruising 

or  lacerating  the  brain,  or  of  producing  hemorrhage  which 

compresses  it.      In  the  former  the  broken  fragment  of  bone 

201 


202  A    CLINICAL    TREATISE    ON  FRACTURES. 

is  the  direct  vulnerating  body,  while  in  the  latter  the  skull 
acts  only  as  a  transmitter  of  the  violent  impact  directed 
upon  it,  and  concussion,  contusion,  laceration,  or  hemor- 
rhage of  the  brain  occurs,  without  fracture  of  the  skull. 
While  technically,  therefore,  fractures  of  the  skull  must  be 
depressed  fractures  in  order  to  possess  surgical  importance, 
all  fractures  which  are  accompanied  by  brain  symptoms, 
and  many  which  are  not,  may  well  be  suspected  of  doing 
harm  until  the  contrary  is  proved  by  exploration.  The 
methods  of  conducting  such  exploration  are  now  so  free  from 
risk  and  can  be  used  so  much  more  satisfactorily  if  they  are 

resorted  to  at  once,  that  delay  is  sel- 

Fig.  99.  J 

dom  advisable,  or  even  justifiable, 
if  proper  technique  and  means  are 
at  hand. 

The  structural  form  and  physical 
constitution  of  the  skull  are  such 
that  a  fracture  of  the  external  table 
may  furnish  little  clue  in  regard  to 
the  existence  of  any  abnormal  con- 
Fracture  of  the  external  table     dition    of    the   internal  table.      Ac- 

of  the  skull.  . 

companymg  a  fracture  01  the  ex- 
ternal table  produced  by  a  hammer  or  sharp  edge  of 
metal  or  stone  there  may  be  decided  depression  of  the 
external  table  with  little  or  no  disturbance  of  the  internal 
table,  as  shown  in  Figs.  99  and  100 ;  there  may  be  a  fracture 
of  the  internal  table  which  corresponds  in  form  and  degree 
of  depression  with  great  accuracy  to  the  fracture  of  the  ex- 
ternal table,  as  shown  in  Fig.  101  ;  or  there  may  be  an  ex- 


FRACTURES   OF  THE   SKULL. 


203 


tensive  depressed  (Fig.  102)  or  stellate  fracture  (Fig.  103)  of 
the  internal  table,  with  a  degree  of  depression  of  the  external 
table  so  slight  as  easily  to  escape  de-  fig.  100. 

tection  through  the  scalp.  Fig.  103 
is  reproduced  from  a  specimen  which 
well  illustrated  this  last  condition. 
The  case  was  one  of  depressed  frac- 
ture of  the  skull  anteriorly,  which 
after  trephining  died.  A  post-mortem 
examination  revealed  a  stellate  frac- 
ture,    Which     is    Shown     in      the     lower     Fracture  of  the  external  table 

portion  of  the  figure,  the  presence  of  of  the  skulL 

which  was  the  principal  cause  of  death.  So  little  depres- 
sion of  the  external  table  accompanied  it  that  it  could  not 

have  been  discovered  through  the 
scalp  if  sought  for;  which  it  was  not, 
because  of  the  existence  of  the  visi- 
ble lesion.  An  extensive  radiating 
fracture  is  very  liable  after  having 
done  great  damage  to  the  brain  or 
dura  mater,  and  having  caused  in- 
tracranial hemorrhage  bv  wounding 
an    artery    or    one    of    the    cerebral 

Depressed  fracture  of  the  exter-        •  .  -,        , 

sinuses,   to  spring  back    again,   more 

nal    table    accompanied    by 

corresponding  depression  of    or  less  completely,  into  position,  thus 

the  internal  table.  •  -.  i  i    i  •  i 

covering  its  tracks  and  leaving  be- 
hind no  trace  of  the  damage  it  has  wrought  within.  While 
the  seat  of  such  fracture  is  usually  at  the  point  of  impact, 
it  may  be  quite  remote  from  it.     If  remote,   the  fossa  most 


Fie 


204 


A    CLINICAL    TREATISE    OX  FRACTURES. 


adjacent  to  the  point  of  impact  on  the  vault  of  the  cranium 
will  frequently  be  the  seat  of  such  indirect  fracture,  con- 
stitutino-  a  fracture  at  the  base  of  the  skull. 


Fig.  102. 


Fig.  103. 


Fracture  of  the  internal  table  of  the 
skull  with  extensive  depression. 


Stellate  fracture  of  the  skull. 


Fractures  at  the  base   of  the  skull,   of  which   Fig.    104 
is  an   example,  may,  however,  be   produced  by  direct  vio- 
fig.  104.  lence,  as  in  a  headlong  fall,  where 

the  skull  is  brought  to  a  stand- 
still and  the  spinal  column,  car- 
rying with  it  the  momentum  of 
the  entire  body,  is  thrust  against 
the  base,  and  is  capable  of  severely 
comminuting  it  or  even  of  being 
driven  straight  into  the  brain. 
Fig.  105  represents  an  extensive 
Fracture  at  the  base  of  the  skull,  comminuted  fracture  of  the  base 
of  the  skull,  produced  by  a  headlong  fall,  which  terminated 
fatally  in  a  few  days.  Post-mortem  examination  revealed 
almost  complete  ankylosis  of  the  cervical  vertebrae,  as  shown 
in  Fig.  106,  a  condition  which  doubtless  contributed  largely 


FRACTURES   OF   THE   SKULL. 


205 


to  the  injury  of  the  skull,  as  the  column  at  this  point,  by 
its  rigiditv,  permitted  no  yielding  of  the  neck,  and  was 
therefore  driven  with  the  force  of  a  solid  pillar.  The  base 
of  the  skull  may  also  be  fractured  by  compression  of  the  head 
laterally,  as  when  the  head  is  run  over  by  a  heavy  wagon. 


Fig.  105. 


Fig.  106. 


I 


Comminuted  fracture  of  the  base  of  the 
skull. 


Ankylosed    cervical   vertebrae  in  the 
case  illustrated  in  Fisc.  10:;. 


Other  forms  of  fracture  of  the  base  of  the  skull  are  punct- 
ured and  gunshot  fractures.  Certain  points,  as  the  orbit  and 
nasal  cavity,  offer  little  resistance  to  such  an  instrument  as 
a  foil  without  its  tip  or  other  light,  delicate  metal  point. 
Many  fractures  of  the  vault  of  the  skull,  especially  those 
produced  by  heavy  blows  and  by  falls,  while  their  actual 
focus  may  be  in  the  vault,  involve  the  base  by  radiating 
lines  of  fracture ;  when  the  symptoms  of  the  one  are 
masked  by  the  other.  Fractures  of  a  parietal  bone  may 
extend  to  the  base  through  frontal,  temporal,  or  occipital 
bones ;  but,  as  already  stated,  the  base  is  more  frequently 
fractured  in  that  fossa  most  adjacent  to  the  point  of  impact 


206  A    CLINICAL    TREATISE    OX  FRACTURES. 

on  the  vault  of  the  skull.  In  such  cases,  while  the  gross 
lesion  is  distinctly  of  the  vault,  symptoms  of  fracture  of  the 
base  are  also  present. 

Fractures  of  the  skull  may  best  be  considered  under 
only  two  varieties,  uncomplicated  and  complicated,  as  per- 
haps in  no  other  way  can  the  all-important  distinction 
between  a  fracture  which  neither  immediately  nor  remotely 
causes  harm  to  the  brain,  and  one  which  does  so  or  is  in 
danger  of  doing  so,  be  so  clearly  emphasized.  Once  this  dis- 
tinction is  made,  they  may  be  described,  as  are  fractures  else- 
where, according  to  the  special  characteristics  they  possess ; 
thus  they  may  be  simple  or  compound.  This,  which  in 
other  bones  is  often  the  most  important  distinction,  plays 
a  very  subordinate  part  in  fractures  of  the  skull.  A  simple 
fracture  causing  a  mere  fissure  in  any  part  of  the  vault  of 
the  cranium,  accompanied  by  moderate  and  evanescent  symp- 
toms of  concussion  of  the  brain,  will  almost  inevitably  escape 
detection,  for  no  sign  indicative  of  its  existence  can  be  felt 
through  the  scalp,  and  the  brain  symptoms  present  are  not 
severe  enough  even  to  suggest  the  necessity  of  making 
an  exploratory  incision.  Or  a  simple  fracture  may  be 
of  a  character  that  will  produce  a  degree  of  injury  to 
the  brain  sufficient  to  cause  almost  immediate  death,  or  a 
condition  which  if  not  immediately  relieved  will  inevitably 
prove  fatal.  A  compound  fracture  may  consist  of  simply 
a  slight  chipping  off  of  a  small  fragment  of  bone  which 
does  no  harm  and  produces  an  injury  which  is  of  the  most 
trifling  importance.  Such  a  condition  is  frequently  found 
accompanying  scalp-wounds,  and  often,  were  the  compound 


FRACTURES   OF   THE   SKULL.  2QJ 

element  emphasized,  it  might  from  a  medico-legal  aspect  be 
given  very  undue  prominence.  On  the  other  hand,  the 
severest  lesions  of  fracture  may  be  present  with  it,  just  as 
they  may  be  with  the  simple  fracture.  The  simple  or  com- 
pound element,  therefore,  in  fracture  of  the  skull  is  often 
an  insignificant  one.  The  latter,  by  making  explora- 
tion of  the  skull  possible  without  the  use  of  an  anaesthetic, 
rather  simplifies  than  complicates  the  management  of  the 
case.  In  the  same  way  linear,  comminuted,  stellate,  and 
impacted  are  terms  which,  while  useful  for  description, 
have  little  bearing  upon  the  severity  of  the  fracture. 
A  minute  linear  fracture  may  have  little  importance,  or 
it  may  be  the  wound  of  entrance  of  a  penknife-blade 
which,  thrust  through  the  skull  into  the  brain,  and  hav- 
ing broken  off  just  below  the  surface  of  the  bone,  has 
left  no  trace  behind.  A  comminuted  fracture,  too,  may  be 
important  or  not,  depending  wholly  upon  other  conditions 
present ;  and  an  impacted  fracture  may  or  may  not  add  in 
some  way  to  the  complexity  of  the  case.  A  depressed  fract- 
ure does  possess  special  characteristics,  to  which  reference 
will  presently  be  made.  It  is  usually  comminuted  and  more 
or  less  impacted ;  while  a  stellate  fracture  is  necessarily 
comminuted,  and  is  likely  to  be  more  or  less  incomplete. 
The  real  importance  in  a  general  classification  of  fractures 
of  the  skull  is  to  distinguish  those  which  involve  no  injury 
to  the  brain,  either  at  the  time  of  their  occurrence  or  at 
a  later  period,  from  those  which  have,  either  by  wounding 
the  brain  or  its  membranes,  or  by  lessening  the  intra- 
cranial  capacity,   produced   those  disturbances  of  the  func- 


208  A    CLINICAL    TREATISE    ON  FRACTURES. 

tions    of  the    brain    which    are    commonly    called    cerebral 
symptoms. 

As  cerebral  symptoms  are  caused  by  so  many  morbid 
conditions  other  than  fracture,  and  as  their  origin,  classifi- 
cation, localization,  and  management  constitute  a  subject 
which  must  be  treated  fully,  if  treated  at  all,  the  description 
of  the  various  fractures  of  the  skull  will  be  rendered  clearer 
and  simpler  if  the  cerebral  disturbances  caused  by  them 
or  associated  with  them  are  not  specifically  described,  but 
only  generally  mentioned  as  the  occasion  requires.  The 
conditions  demanding  surgical  interference  in  fracture  of  the 
skull  are  much  more  frequently  those  which  are  local  than 
those  which  are  general.  If  there  is  a  wound  leading  to  the 
seat  of  fracture,  the  existence  of  the  latter  being  immedi- 
ately revealed,  its  proper  management  may  often  be  definitely 
determined  upon  without  regard  to  the  presence  or  absence 
of  cerebral  symptoms.  In  the  same  way  the  probability  of 
fracture  may  be  suggested  by  nothing  more  than  the  exist- 
ence of  a  boggy  spot  in  the  scalp.  While  the  presence  of 
cerebral  symptoms  accompanying  such  a  local  condition 
would  point  yet  more  strongly  to  the  probability  of  there 
being  a  fracture  and  to  the  necessity  for  exploration,  the 
absence  of  such  symptoms  would  in  no  wise  negative  the 
existence  of  fracture.  It  must  be  mentioned,  however,  in 
qualification  of  this  statement  that  there  are  a  certain  num- 
ber of  fractures  of  the  skull,  especially  those  of  limited  area, 
in  which  localization  is  of  inestimable  value  in  indicating 
with  extraordinary  precision  the  site  of  the  lesion.  The  lat- 
ter is  in  these  cases  usuallv  hemorrhaofe  caused  bv  fracture  or 


FRACTURES   OF   THE   SKULL.  200, 

cranial  jar.  While,  as  already  stated,  an  intracranial  lesion 
at  any  point  may  produce  general  symptoms  identical  in  all 
respects  with  those  due  to  fracture,  when  such  symptoms  are 
present,  fracture  being  practically  the  only  removable  cause, 
it  becomes  a  matter  of  the  very  first  importance  to  prove  or 
eliminate  its  presence.  Cerebral  localization  is  often  of  value 
in  placing  the  lesion  at  some  particular  point ;  but  owing  to 
the  preponderance  after  fracture  of  symptoms  produced  by 
brain  concussion  or  brain  contusion,  the  aid  it  might  render 
is  not  by  any  means  as  great  as  that  afforded  by  it  in  the 
diagnosis  of  diseased  conditions.  If  these  symptoms  are  not 
so  marked  as  to  overwhelm  completely  those  of  localization, 
there  may  be  observed  occasionally  faint  twitching  of  the 
arm  and  leg  on  one  side,  indicating  the  involvement  of  the 
arm  and  leg  centre  on  the  opposite  side  of  the  brain  as  the 
probable  focus  of  the  lesion.  In  like  manner  other  symp- 
toms may  locate  the  lesion  at  a  particular  point  in  the  skull, 
as  indicated  by  cerebral  topography. 

The  frequency  with  which  fracture  of  the  skull  is 
mistaken  for  various  other  conditions  sufficiently  indicates 
the  necessity  of  carefully  eliminating  it  by  the  most 
thorough  exploration  of  the  scalp  in  every  case  of  coma 
or  paralysis  which  cannot  be  clearly  accounted  for  by 
surrounding  circumstances.  Such  mistakes  are  most  com- 
monly made  by  the  ignorant,  as  when  an  unconscious  in- 
dividual is  placed  in  a  cell  at  a  station-house,  thought  to 
be  a  subject  of  alcoholic  coma,  when,  albeit  he  may  be  satu- 
rated with  spirits,  he  is  found  perhaps  after  death  to  have  a 
fracture  of  the  skull.      But  errors  of  this  nature  occasionally 

14 


2IO  A    CLINICAL    TREATISE    ON  FRACTURES. 

occur  in  technical  hands,  sometimes  unavoidably,  but  too 
frequently  from  carelessness.  In  every  such  case,  there- 
fore, to  which  the  surgeon  is  summoned,  whether  alcoholic 
intoxication,  uraemia,  or  apoplexy  be  the  apparent  cause 
of  the  symptoms  present,  the  possible  presence  of  fracture 
should  be  borne  in  mind  and  sought  for.  If  upon  exami- 
nation any  doubtful  spot  be  discovered,  the  scalp  should  at 
this  point  be  shaved,  in  order  that  the  examination  may 
benefit  by  inspection  of  the  color  of  the  skin  and  by  the 
improved  opportunity  for  palpation.  If  such  a  case  recov- 
ers consciousness,  he  should  be  kept  under  careful  obser- 
vation for  a  sufficient  period  to  prove  that  his  symptoms 
were  toxic  and  not  traumatic. 

Diagnosis. — The  diagnosis  of  fracture  of  the  vault  of 
the  skull  is  based  on  the  evidence  obtained  by  inspection 
and  palpation,  which  in  the  absence  of  an  external  wound 
often  furnish  but  meagre  data,  and  on  the  presence  of  cere- 
bral symptoms,  if  they  exist.  When  it  is  remembered  that 
symptoms  of  every  degree  of  concussion,  of  contusion,  and 
of  laceration  of  the  brain  may  be  present  without  fracture, 
and  that  symptoms  related  to  one  of  these  conditions  are 
often  present  in  conjunction  with  fracture,  though  probably 
not  depending  wholly  upon  it,  it  is  evident  that,  without 
exploration,  in  many  cases  the  question  of  existence  of 
fracture  will  always  remain  in  doubt.  A  depressed  fracture 
of  the  skull  requires  surgical  intervention,  not  only  on  ac- 
count of  the  damage  it  may  have  already  inflicted  upon  the 
dura  mater  or  brain,  and  may  continue  to  inflict  for  the 
present  by  causing  paralysis,  hemorrhage,  and  a  little  later 


FRACTURES   OF  THE  SKULL. 


211 


abscess,  but  also  on  account  of  the  remote  cerebral  diseases 
(epilepsy,  chronic  meningitis,  and  dementia)  which  are  not 
such  uncommon  sequelae  that  we  can  afford  for  a  moment 
to  ignore  them. 

If  with  cerebral  symptoms — and  the  term  is  intended  as 
here  used  to  denote  disturbances  of  a  more  grave  character 
— is  combined  a  contusion  extending  over  a  considerable 
area,  the  central  portion  of  which  feels  soft  and  boggy, 
incision  will  frequently  reveal  a  fracture.      Figure  107  illus- 


Fig.  107. 


trates  a  very  extensive  commi- 
nuted depressed  fracture  which 
occurred  under  these  conditions, 
but  which,  as  there  was  no 
wound  of  the  scalp,  it  remained 
for  the  exploratory  incision  to 
reveal.  Again,  in  certain  cases 
which  present  symptoms  of 
great  compression  of  the  brain 
occurring  after  a  fall  from  a 
height  where  the    head  strikes 

Soft    ground,    and    the    impact    is     Diagram  of  simple  fracture  of  the  skull, 

showing  the  central  area  of  depres- 
SO    distributed    Over   a   large    SUr-  sion  and  the  radiating  lines  of  fract- 

face  of  scalp  as  to  cause  no  ap-       ure-    The  flaP  is  indicated  by  the 

curved  dotted  line. 

preciable  contusion  at   any  one 

point,  it  may  be  extremely  difficult  to  select  a  likely  point 
for  exploration,  and  perhaps  even  after  one  exploration  has 
been  made  nothing  more  will  have  been  learned  than  that 
there  is  no  fracture,  at  least  at  the  location  explored.  The 
following  case  well  illustrates  such  a  condition:  A  boy  of 


212  A    CLINICAL    TREATISE    OX  FRACTURES. 

twelve  years  was  brought  to  the  Episcopal  Hospital  in  a 
state  of  complete  coma  and  suffering  general  shock,  having 
fallen  from  a  height.  Though  he  evidently  had  great  com- 
pression of  the  brain,  careful  inspection  and  palpation  of 
the  scalp  showed  no  contusion  and  no  appreciable  change 
in  contour  at  any  portion.  Extravasation  of  blood  into  the 
orbits,  both  right  and  left,  was  so  extensive  that  the  eye- 
lids bulged  out  into  the  form  of  two  half-spheres,  dark 
blue  in  color.  This  one  symptom  pointed  to  fracture 
of  the  anterior  part  of  the  skull.  A  transverse  incision 
carried  across  the  vertex  from  temple  to  temple  revealed 
depression  of  the  whole  frontal  bone,  the  line  of  incision 
happening  to  have  been  so  planned  that  it  coincided  almost 
throughout  its  course  with  the  line  of  fracture;  points  of 
action  for  two  levers  were  obtained  by  two  small  trephine- 
openings  in  either  parietal  bone  and  the  frontal  bone  was 
readily  elevated  into  position.  The  boy  made  a  complete 
recovery. 

A  depressed  fracture  of  the  skull  may  occasionally  be 
detected  by  palpation  through  the  scalp,  but  similar  changes 
in  subcutaneous  contour  to  those  felt  in  such  fractures  are 
much  more  frequently  produced  by  indurated  cellular  tissue 
abruptly  terminating  in  soft  yielding  depressions,  caused 
bv  adjacent  portions  being  dense  through  oedema  or  yield- 
ing through  effusion  of  blood.  Little  importance  can  there- 
fore be  attached  to  irregularities  present,  even  though  they 
feel  like  bony  irregularities. 

A  fracture  of  the  skull  may  occur  at  a  point  remote 
from  that  of  the  impact.     This  is,  however,   the  exception, 


FRACTURES    OF   THE   SKULL.  21 3 

for  the  bone  is  much  more  likely  to  yield  where  it  is 
struck  ;  and  if  the  body  inflicting  the  blow  is  of  a  shape  to 
divide  the  integument  the  scalp  wound  present  will  usually 
lead  directly  to  the  fracture,  and  it  will  be  possible  to  detect 
the  latter  by  means  of  a  probe  if  the  wound  is  small,  or 
with  the  finger  if  the  wound  be  large  enough  to  admit  it. 

The  symptoms  of  fracture  at  the  base  of  the  skull  are 
few  and  often  not  very  characteristic.  Fracture  of  the 
anterior  fossa  causes  epistaxis,  loss  of  smell,  and  subcon- 
junctival ecchymosis.  The  blood  may  fill  the  orbits,  and 
even  cause  false  aneurism.  In  the  absence  of  contusion 
of  the  eyes  and  of  fracture  of  the  nose  these  symptoms  sug- 
gest the  possibility  of  fracture  of  the  base  anteriorly. 
Symptoms  indicating  fracture  of  the  middle  cerebral  fossa 
are  bleeding  from  one  or  both  ears,  succeeded  in  a  day  or 
two  by  exudation  of  cerebrospinal  fluid;  there  may  be 
facial  paralysis ;  and  intellection  may  be  wholly  unim- 
paired, or  there  may  be  delirium  or  coma.  Few  signs  point 
with  any  certainty  to  fracture  of  the  cerebellar  fossa. 
There  may  be  hemorrhage  from  the  pharynx,  or  blood, 
being  extravasated  into  the  cellular  tissue  of  the  neck, 
may  appear  as  an  ecchymosis  about  the  ear.  Fracture  of 
the  base  most  frequently  involves  the  middle  fossa;  and  if, 
after  a  severe  injury,  a  flow  of  cerebrospinal  fluid  follows 
bleeding  from  one  or  both  ears,  and  the  flow  continues,  the 
presence  of  fracture  may  be  fairly  assumed. 

Prognosis. — Fracture  of  the  vault  of  the  skull  is  not  a 
very  fatal  injury,  if  the  cases  in  which  the  damage  done  is 
so  great  as  to  cause  immediate  death  are  excluded.     While 


214  A    CLINICAL    TREATISE    OX  FRACTURES. 

it  would  appear  almost  useless  to  formulate  any  rules  upou 
which  to  base  an  opinion  regarding  the  outcome  of  a  con- 
dition subject  to  such  a  wide  range  of  variation  in  locality, 
extent,  and  severity,  it  may  be  stated  that  a  large  propor- 
tion of  fractures  of  the  skull  which  survive  long  enough  to 
come  under  the  care  of  the  surgeon  recover.  It  is  encour- 
aging, too,  to  observe  that  of  these  cases  there  are  com- 
paratively few  in  which  the  recovery  is  not  complete  and 
permanent.  Fractures  of  the  base  are  very  fatal,  though 
recovery  occurs  even  after  them.  When  it  does  so,  there 
mav  be  at  times  an  element  of  uncertainty  reo-ardinsf  the 
correctness  of  the  diagnosis.  Among  the  immediate  causes 
of  death  from  fracture  of  either  vault  or  base  are  menin- 
gitis, cerebritis,  pressure  from  hemorrhage,  and  cerebral 
abscess.  The  more  remote  conditions  liable  to  give  trouble 
are  chronic  meningitis,   dementia,   and  epilepsy. 

Treatment  of  Fractures  of  the  Skull. — From 
what  has  already  been  said,  it  is  evident  that  in  all  simple 
fractures  of  the  skull,  diagnosis  and  treatment  are  corre- 
lated. Diagnosis  is  dependent  in  many  cases  wholly  upon 
exploration,  while  the  proper  line  of  treatment  becomes 
manifest  only  when  a  definite  diagnosis  is  thus  obtained. 
As  the  diagnosis  of  compound  fractures,  so  far  as  their 
superficial  character  is  concerned,  is  rendered  immediately 
patent  by  the  presence  of  the  wound,  this  primary  element 
in  the  management  of  the  case — i.  £.,  thorough  exploration 
— does  not  obtain.  The  question,  What  local  and  general 
symptoms  point  with  sufficient  distinctness  to  the  possible 
existence    of    fracture    to   warrant    exploration,    should    be 


FRACTURES   OF  THE  SKULL.  21 5 

answered  by  enumerating  not  the  gravest  symptoms, 
because  they  speak  for  themselves,  but  the  mildest:  marked 
concussion  which  in  twelve  hours  shows  no  improvement; 
contraction  of  one  pupil  more  than  the  other;  slight  con- 
vulsive twitchings  of  an  arm  or  a  leg;  irritability  which 
is  out  of  proportion  to  the  degree  of  primary  shock  of  con- 
cussion; the  history  of  the  injury  indicating  its  character 
as  one  liable  to  cause  fracture;  and,  finally,  the  presence  at 
some  point  in  the  scalp  of  a  spot  which,  though  perhaps 
very  small,  is  soft  and  boggy  and  is  surrounded  by  an  indu- 
rated border.  Symptoms  less  than  these  seldom  warrant 
exploration,  for  although  a  procedure  of  small  surgical 
importance,  it  should  not  under  certain  conditions  and 
surroundings  be  lightly  undertaken,  but  should  unhesitat- 
ingly be  advised  if  sufficient  evidence  of  fracture  exists  to 
prevent  chagrin  were  it  followed  by  a  negative  result.  If, 
therefore,  in  a  case  of  suspected  fracture  of  the  skull  unac- 
companied by  a  wound  of  the  scalp,  it  is  decided  to  explore, 
preparation  for  such  exploration  should  be  as  complete  as 
the  preparation  necessary  before  trephining,  and  in  all 
respects  identical  with  it. 

A  large  area  surrounding  the  proposed  site  of  operation 
should  be  carefully  shaved.  Indeed,  it  is  better,  if  prac- 
ticable, to  have  the  entire  scalp  shaved.  After  the  skin 
has  been  properly  prepared,  an  incision  down  to  the  bone 
large  enough  to  admit  the  entrance  of  the  finger  should 
be  so  planned  that  it  shall  include  part  of  the  edge  of  an 
oval  or  circular  flap,  which  may  afterwards  be  dissected 
up.     Should  the  fracture  prove  extensive  it  may-  be  neces- 


2l6 


A    CLINICAL    TREATISE    ON  FRACTURES. 


sary  to  make  two  or  even  three  flaps  in  order  clearly  to 
expose  the  field  of  operation.  These  may  conveniently 
be  kept  out  of  the  way  by  being  turned  back  and  pinned, 
as  shown    in    Fig.    108,   which  represents  a  case  of  exten- 


Fig.  108. 


Extensive    depressed    fracture    of  the   skull    prepared   for  trephining,   showing    flaps 
pinned  back  out  of  the  way. 

sive  fracture  with  depression  about  to  be  trephined. 
The  only  general  rule  for  the  formation  of  such  a  flap  is 
that  its  convexity  shall  look  downwards  in  relation  to  the 
position  of  the  head  when  the  patient  is  in  a  state  of 
recumbency.  The  flap  is  formed  in  this  direction  for  pur- 
poses of  drainage.  Should  the  first  incision  reveal  the 
existence  of  fracture  with  even  slight  localized  depression, 
the  skin-wound  should  be  increased  in  size  enough  to  allow 
careful  inspection  of  the  skull.  The  depression,  if  small, 
may  be  all  included  within  the  cut  of  a  three-quarter  inch 
trephine ;  if  extensive,  elevation  is  accomplished  with  or 
without  the  use  of  a  trephine.  In  applying  the  trephine 
over  a  limited  point  of  depression  where  the  latter  is 
intended    to  remove  a  button  which  will    include    the    full 


FRACTURES    OF   THE   SKULL.  2\y 

extent  of  the  depressed  portion  of  bone,  the  centre-point 
of  the  instrument  must  be  made  to  project  far  enough  from 
the  teeth  to  reach  down  to  the  deepest  part  of  the  depression, 
in  order  to  centre  the  instrument  until  it  engages.  Should 
removal  of  the  button  reveal  the  existence  of  a  stellate 
fracture  of  the  internal  table,  the  apex  of  the  depression 
will  in  all  probability  be  found  to  have  been  removed  in 
the  button;  but  very  careful  examination  should  be  made 
around  the  periphery  of  the  opening  lest  some  spur  of 
the  internal  table  still  exists  at  a  point  beyond. 

According  as  the  radius  of  the  fracture  is  found  to  be 
slight  or  extensive,  any  further  depressed  portion  if  impacted 
is  removed  with  trephining-forceps  or  with  a  second  applica- 
tion of  the  trephine  at  a  point  immediately  adjacent  to  the 
first,  the  narrow  neck  of  bone  separating  the  two  trephine- 

FlG.   109. 


Author's  trephining-forceps. 


openings  being  excised  with  the  trephining-forceps  (Fig. 
109).  When,  on  exploration,  the  fracture  is  found  to  be 
comminuted  and  much  depressed,  a  liberal  flap,  extending 
for  one-third  of  a  circle  with  a  radius  of  two  inches,  may 


2l8  A    CLINICAL    TREATISE    ON  FRACTURES. 

be  dissected,  or,  as  its  under  surface  has  iisually  been  com- 
pletely detached  from  the  bone  by  the  injury,  simply  lifted 
up,  reflected  over,  and  kept  out  of  the  way  by  long  pins 
introduced  through  it  and  into  the  scalp  in  the  manner 
just  described.  The  field  of  operation  should  in  no  case 
be  restricted,  and  flaps  in  other  directions  may  have  to  be 
made  in  order  to  give  ready  access  to  new  lines  of  fracture 
which  are  found  during  the  operation.  In  comminuted 
depressed  fractures  a  point  of  action  for  a  lever  may  be 
made  by  removing  some  small  fragment  of  bone,  which, 
having  been  picked  up  with  the  corner  of  a  chisel,  may 
readily  be  detached,  or  such  a  point  may  be  made  in  the 
sound  bone  surrounding  the  fracture  with  a  one-half  inch 
trephine.  The  latter  should  be  so  applied  that  two-thirds 
of  its  cut  will  occupy  sound  bone,  the  other  one-third  being 
free  of  its  edge.  A  lever  introduced  into  the  opening  thus 
made  will  readily  act  on  the  depressed  bone,  and  will  ele- 
vate it  to  its  proper  level,  frequently  carrying  along  with 
it  other  depressed  fragments  with  which  it  is  interlocked. 
The  propriety  of  removing  a  depressed  fragment  or  de- 
pressed fragments,  or  simply  elevating  them  into  position, 
depends  (a)  upon  whether  there  is  reason  to  suspect  the 
presence  of  a  fragment  of  the  internal  table  which  remains 
depressed  after  the  external  table  has  been  restored,  and 
(b)  upon  the  probable  existence  of  any  injury  to  blood- 
vessels, dura  mater,  or  brain  produced  by  the  fracture, 
and  concealed  by  the  fragment.  In  many  cases  of 
depressed  fracture  the  element  of  indentation  or  punct- 
ure is  evidently  wanting.     The   depressed   area   of  bone  is 


FRACTURES   OF   THE   SKULL.  2IO. 

composed  of  irregularly  formed  fragments,  which  present 
very  much  the  appearance  of  a  cracked  egg-shell.  In  these 
the  fracture  of  the  internal  table  will,  as  a  rule,  be  found 
to  correspond  with  comparative  accuracy  to  the  lines  of  the 
fracture  of  the  external  table,  and  in  most  of  such  cases 
there  is  no  stellation.  The  assumption  is,  therefore,  suffi- 
cient to  warrant  not  removing  the  fragments  in  order  to 
inspect  the  internal  table,  particularly  if  the  depressed  area 
is  extensive  and  the  removal  of  all  the  fragments  contribut- 
ing to  it  would  leave  a  large  gap  in  the  skull.  As  hemor- 
rhage accompanies  injury  to  an  artery  (middle  meningeal), 
to  a  cerebral  sinus,  and  usually  to  the  dura  mater  or  brain, 
evidences  of  it  must  be  carefully  sought  for.  Hemorrhage 
beneath  the  scalp,  though  usually  resulting  from  an  injury 
to  a  scalp-vessel,  may  proceed  from  beneath  the  skull,  leak- 
ing through  the  lines  of  fracture.  When  from  the  latter 
source  these  lines  are  usually  to  be  found  filled  with  clot — 
a  strong  indication  that  the  hemorrhage  is  intracranial. 
In  such  cases  the  present  requirements  outweigh  the  dis- 
advantage of  a  large  gap  in  the  skull,  and  it  becomes 
necessary  to  ascertain  immediately  the  cause  of  the  hemor- 
rhage. Removing  one  fragment  of  depressed  bone  will 
readily  demonstrate  the  presence  of  a  clot  beneath;  and  if 
it  is  found  to  be  extensive  and  its  locality  suggests  the 
probability  of  lesion  of  an  artery  or  sinus,  other  fragments 
should  also  be  at  once  removed.  At  this  stage  one  of  two 
conditions  will  usually  present  itself:  (i)  the  removal  of  the 
bone-pressure  from  the  wounded  vessel  will  allow  of  free 
hemorrhage,  which  may,  fortunately,  be  sufficiently  exposed 


220  A    CLINICAL    TREATISE    OX  FRACTURE'S. 

to  be  controlled  by  one  method  or  another ;  or  (2)  the  clot 
being  removed  from  the  prepared  area,  the  hemorrhage  is 
found  to  have  proceeded  from  a  point  at  which  it  cannot 
be  readily  arrested  without  further  clearing  the  field  by 
the  removal  of  sound  bone.  Removal  of  the  exposed  clot, 
if  this  is  the  case,  will  seldom  cause  further  hemorrhage, 
and  the  alternative  of  trusting  to  there  being  no  recurrence 
of  hemorrhage  may  be  justifiable,  particularly  if  the  best 
surgical  technique  is  not  at  hand.  If  it  is  decided  to  search 
for  the  bleeding  point  and  secure  it,  a  three-quarter  inch 
trephine  should  be  applied  and  a  disk  removed  at  a  point 
which   will    leave   the   bridge   of   bone    to   be    removed   by 

Fig.  iio. 


Author's  lever  and  fulcrum. 

trephining  forceps  not  wider  than  half  an  inch.  On  removal 
of  this  bridge  of  bone  a  new  field  of  one  and  a  quarter 
inches  will  be  obtained,  which  will  in  all  probability  clearly 
expose  the  bleeding  vessel.  As  the  point  selected  thus  to 
apply  the  trephine  will  most  frequently  be  over  either  the 
course  of  the  middle  meningeal  artery,  great  longitudinal 
sinus,  or  lateral  sinus,  great  care  must  be  exercised  in 
removing  the  disk  of  bone  so  clearly  and  neatly  that  no 
new  lesion  is  caused  to  the  frail  structure  beneath  by  the 
instrument  cutting  too  far. 

When  through   the   removal  of  a  large  portion  of  bone 


FRACTURES   OF   THE   SKULL. 


221 


an  extensive  gap  leaves  no  point  upon  which  to  rest  a  lever 
to  elevate  depressed  fragments  still  remaining,  the  gap  may 
be  conveniently  spanned  at  any  point  by  the  fulcrum  shown 
in  Fig.  no,  upon  which  the  lever  acts.  These  instruments 
are  very  useful  for  this  purpose.  The  fulcrum  being  roughed 
on  its  lower  surface  engages  firmly,  while  the  lever  is  looped 
so  near  its  tip  that  its  action  is  powerful  and  under  perfect 
control.  The  manner  in  which  these  instruments  are  used 
is  shown  in   Fig.    in.     As   already  mentioned,   sources  of 

Fig.  hi. 


Showing  the  action  of  lever  and  fulcrum  in  spanning  wide  gaps  in  the  skull. 

serious  hemorrhage  occurring  after  fracture  of  the  skull 
are  either  one  of  the  cerebral  sinuses  or  the  middle  menin- 
geal artery.  Hemorrhage  from  the  longitudinal  or  lateral 
sinus  usually  requires  to  be  controlled  after  the  fragment  of 
bone  which   has   punctured    it  is    removed.     Although    the 


222  A    CLINICAL    TREATISE    ON  FRACTURES. 

hemorrhage  is  profuse,  it  need  not  cause  alarm,  as  the 
slightest  weight  of  a  finger  easily  controls  it.  There  need 
be,  therefore,  no  haste.  A  very  delicate,  curved  needle 
threaded  with  silk  or  fine  catgut  should  be  prepared,  and 
the  attempt  made  to  approximate  the  edges  of  the  sinus 
wound  by  the  introduction  of  a  suture  at  two  points. 
Closure  in  this  way,  however,  can  seldom  be  successfully 
done.  The  sinus' wall  is  so  inelastic  that  the  suture  may 
pull  through  before  approximation  is  sufficiently  perfect  to 
stop  the  bleeding.  In  the  cases  that  I  have  met  of  wound 
of  the  longitudinal  and  lateral  sinuses  hemorrhage  was  per- 
manently controlled  by  the  use  of  simply  a  small  gauze 
compress,  removed  at  the  end  of  three  or  four  days.  In  one 
or  two  instances  such  a  compress  was  used  after  failure  to 
control  the  hemorrhage  by  suture.  When  the  middle  menin- 
geal artery  is  torn,  hemorrhage  from  it  is  not  infrequently 
found  on  trephining  to  have  ceased  spontaneously.  Should 
the  vessel  continue  to  bleed,  or  start  afresh  to  do  so  on 
removal  of  the  clot,  a  very  delicate  suture  of  catgut  or  silk 
may  be  passed  around  it  just  below  the  wounded  point; 
or  the  hemorrhage  may  be  controlled,  as  from  a  sinus,  by 
a  small  compress  of  gauze.  The  latter  can  frequently  be 
insinuated  just  beneath  the  edge  of  sound  bone,  there  to 
remain  four  or  five  days,  when  it  can  be  pulled  out  by  its 
free  extremity,  which  has  been  carried  to  some  convenient 
point  in  the  scalp-wound. 

The  management  of  tears  of  the  dura  mater  varies 
according  to  their  character  and  extent.  Clean  tears  should 
always   be   sutured,  preferably    with   fine   catgut;   but   nice 


FRACTURES    OF   THE   SKULL.  22$ 

approximation  of  contused,  ragged  tears  by  suture  is 
impracticable.  Specially  careful  sterilization  of  the  latter 
and  of  the  whole  wound  is  the  best  safeguard  against  fungus 
cerebri.  This  mischievous  complication,  while  yet  liable 
to  happen,  has  happily  been  very  much  lessened  in  fre- 
quency by  clean  surgery. 

Various  methods  have  been  employed  to  protect  the 
brain  from  future  injury  after  the  removal  by  trephining 
of  an  extensive  area  of  bone.  Certain  it  is  that  unless  a 
very  considerable  portion  of  skull  is  removed  little  pro- 
tection is  necessary,  for  not  only  is  the  vulnerable  point 
usually  much  depressed  below  the  level  of  the  surrounding 
osseous  wall,  but  the  scar  tissue  covering  it  well  resists 
all  ordinary  impacts.  When  it  is  desired  to  make  the 
attempt  to  close  a  hiatus  with  new  bone,  the  following 
method  I  have  found  very  satisfactory:  the  dura  mater  is 
protected  by  a  thin  layer  of  connective  tissue  which  has 
been  shaved  off  from  the  under  surface  of  the  flap  of  a 
size  and  shape  to  fit  the  gap.  Upon  this  is  spread  a  layer 
of  chopped  bone  prepared  from  some  of  the  fragments 
which  have  been  removed.  The  bone  should  be  reduced 
to  particles  the  size  of  coffee  grounds  by  ronguer  forceps, 
and  should  be  kept  warm  and  sterile  until  used.  The  layer 
of  chopped  bone  is  kept  in  place  by  the  scalp  flap.  This 
method  I  have  employed  in  a  number  of  cases  without 
drawback,  and  in  those  which  I  have  been  able  to 
follow  long  enough  have  found,  without  exception,  good 
bony  restoration.  The  return  of  the  button  intact,  or 
of    removed     fragments,    I     have     never    attempted.       The 


224  A    CLINICAL    TREATISE    ON  FRACTURES. 

scalp-wound  may  be  approximated  by  catgut  sutures,  and 
it  is  desirable  to  insert  a  few  strands  of  drainage-catgut 
leading  out  from  the  trephined  point,  and,  if  the  flap  is 
large,  from  its  angles.  The  retention  of  a  liberal  gauze 
pad  by  a  recurrent  bandage  completes  the  dressing  of 
the  wound.  The  patient's  general  management  is  in  many 
cases  simple.  Small  doses  of  calomel,  along  with  absolute 
quiet  and  freedom  from  all  excitement,  best  lessen  the  ten- 
dency to  cerebritis.  Little  or  no  food  for  the  first  day,  fol- 
lowed by  a  liquid  diet  until  all  risk  of  inflammatory  reac- 
tion has  passed,  should  be  used.  The  dressing  should  be 
changed  on  the  following  day  should  much  oozing  have 
occurred  ;  but  if  it  appears  dry  and  clean  it  may  be  allowed 
to  remain  on  for  five  days  or  more.  In  cases  that  progress 
favorably  little  treatment  is  required.  The  accompanying 
symptoms  of  concussion  usually  present  subside  in  forty- 
eight  hours.  The  patient's  face  assumes  a  comfortable, 
natural  expression;  he  is  free  from  irritability  and  restless- 
ness, and  seldom  complains,  even  of  headache.  In  such 
cases  the  operative  cure  is  rapid,  and  cerebral  sequelae  are 
not  to  be  apprehended.  Indeed,  as  far  as  we  have  data 
relating  to  the  liability  to  the  several  remote  consequences 
of  fracture  of  the  skull,  they  appear  to  be  rare  or  fre- 
quent in  direct  proportion  to  the  lightness  or  severity  of 
the  symptoms  immediately  following  the  injury.  There  is 
reason  to  believe  that  a  very  large  proportion  of  trephined 
fractures  of  the  skull,  accompanied  by  nothing  worse  than 
slight  concussion  of  the  brain,  recover  perfectly  and  perma- 
nently; and  that  the  beginning  of   those  changes,    menin- 


FRACTURES   OF   THE   SKULL. 


225 


geal  or  cerebral,  which  finally  develop  epilepsy,  insanity,  or 
some  other  nervous  disease,  dates  from  and  is  caused  by  the 
inflammatory  reaction  immediately  following  the  injury 
which  produces  the  series  of  symptoms  clearly  indicative 
of  its  presence.  Thus  in  a  case  of  an  extensive  compound 
fracture  of  the  skull  (Fig.    112)  I  had  occasion  to  trephine 

Fig.  112. 


Compound    depressed    fracture  of  the  skull    accompanied   by  wound  of  the   longi- 
tudinal sinus. 

the  injury  was  caused  by  the  man  being  hurled  from  the 
top  of  a  freight  car  going  at  speed,  by  the  parting  of  his 
brake-lever.  The  brain  was  severely  contused  and  the 
longitudinal  sinus  torn.  The  symptoms  of  cerebritis  were 
so  marked,  as  evidenced  by  a  semiconscious  delirium,  that 
for  forty-eight  hours  he  required  the  constant  restraint  of 
two  attendants.  His  mental  condition  from  the  first  return 
of  consciousness,  at  the  end  of  two  days,  was  characterized 
by  perfect    imbecility.      The   restlessness   had    disappeared, 

15 


226  A    CLINICAL    TREATISE    OX  FRACTURES. 

and  he  would  lie  upon  his  right  side,  staring  vacantly 
around  him.  He  paid  no  attention  to  what  was  said  to 
him,  and  indeed  showed  no  recognition  of  anything,  except 
when  winked  at  he  would  always  wink  in  return.  At 
the  beginning:  of  the  second  week  intellection  began  to 
improve,  when  it  was  found  that  his  memory  was  entirely 
gone.  He  had  forgotten  his  age,  how  many  children  he 
had,  and  their  names.  This  symptom  persisted  long  after 
his  mental  condition  was  otherwise  restored,  eight  weeks 
after  the  accident  still  being  unable  to  remember  all  of  the 
stations  on  the  railroad  where  he  was  employed.  He  had 
no  headache  at  any  time,  and  seldom  complained  even  of 
discomfort  at  the  seat  of  injury. 

Here  then  we  have  the  historv  of  great  violence  causing 
almost  fatal  brain  injury,  severe  cerebritis,  and  recovery 
with  a  single  mental  deficiency.  When  a  depressed  fracture 
of  the  skull  is  accompanied  by  cerebral  symptoms,  the 
immediate  relief  of  these  by  trephining  need  hardly  be 
expected,  for  when  it  is  remembered  that  such  symptoms 
are  not  usually  produced  by  the  depressed  fragments  of 
bone  alone,  but  are  provoked  by  the  jar,  contusion,  or 
laceration  of  the  brain  coincident  with  the  fracture,  or  by 
pressure  of  a  blood-clot,  it  will  be  seen  that  elevation  of 
fragments  of  bone,  apart  from  removing  one  positive  cause 
of  compression,  may  only  produce  its  good  effects  hours 
later,  by  giving  free  outlet  to  effused  blood  and  serum,  and 
space  for  inflammatory  cedema  of  contused  cerebral  tissue. 

Efforts  to  lessen  inflammatory  reaction,  when  present, 
should    be    directed    generally   by    depletion    and    counter- 


FRACTURES   OF   THE   SKULL.  227 

irritation,  and  locally  by  perfect  drainage  and  careful  atten- 
tion to  the  wound,  and  the  application  of  an  ice-cap  to  the 
head.  Bromide  of  potassium  may  often  be  given  quite 
freely  to  control  restlessness  or  delirium.  Depletion  is  best 
practised  by  the  use  of  small  doses  of  calomel,  and  occasion- 
ally, should  the  patient's  strength  permit,  an  active  purge. 
Mustard  poultices  to  the  thighs  and  blistering  collodion 
to  the  back  of  the  neck  sometimes  seem  to  be  of  use. 


CHAPTER    VIII 
FRACTURES   OF   BONES    OF   THE    FACE. 

FRACTURES    OF    THE    NOSE. 

Fracture  of  the  nasal  bones  is  caused  by  direct  impact 
in  front  or  at  the  side;  and  though  often  only  one  bone  is 
broken,  the  fracture,  which  is  apt  to  be  transverse,  may 
involve  both.  The  deformity  resulting  from  such  fracture, 
whether  one  bone  or  both  be  broken,  is  usually  lateral; 
though,  particularly  in  cases  in  which  the  injury  has 
extended  to  the  perpendicular  plate  of  the  ethmoid  bone, 
the  deformity  may  be  depressed  in  character,  which  causes 
flattening  of  the  nose.  In  such  cases,  if  only  the  perpen- 
dicular plate  of  the  ethmoid  bone  is  fractured,  no  serious 
symptoms  are  to  be  apprehended;  but  if  the  injury  has 
extended  to  the  cribriform  plate  a  portion  of  the  base  of 
the  skull  is  liable  to  be  implicated,  with  its  attendant  risks. 
If  the  line  of  fracture  of  the  nasal  bone  encroaches  upon 
the  lachrymal  duct,  occlusion  of  the  latter,  followed  by 
abscess  or  fistula,  occasionally  results.  Sometimes  the  force 
causing  the  fracture  acts  in  such  a  manner  as  to  split  the 
nose  away  from  the  face.  If  the  force  has  been  sufficient 
to  fracture  the  cribriform  plate  of  the  ethmoid,  some  degree 
of  concussion  of  the  brain  is  likely  to  occur.  The  profuse 
bleeding  which  accompanies  fracture  of  the  nose  seldom 
requires  attention,   for  it  usually  ceases   spontaneously.      If 

228 


FRACTURES   OF  BOXES   OF   THE   FACE.  229 

it  should  not,  it  may  be  necessary  to  plug  the  nose.  A 
very  rare  complication  of  fracture  of  the  nose  is  emphy- 
sema into  adjacent  cellular  tissue,  extending  into  the  eve- 
lids.  The  contusion  of  the  integument  causes  such  quick 
and  marked  swelling  that  the  presence  of  fracture  is  in 
many  cases  masked,  and  can  only  be  revealed  by  a  careful 
examination.  This  accounts  for  the  unsightly  distortions 
of  the  nose  which  follow  when  either  the  fracture  has  been 
altogether  unrecognized  or  the  displacement  incident  to  it 
incompletely  restored.  Some  deformity  follows  after  the 
separation  even  of  the  nasal  cartilages,  and  it  is,  therefore, 
proper  when  these  alone  are  involved,  for  the  surgeon  to 
explain  clearly  the  nature  of  the  injury,  for  the  least  irreg- 
ularity observed  after  recovery  will  always  be  attributed  by 
the  patient  and  his  friends  to  a  "  broken  nose."  As  the 
community,  therefore,  draws  no  fine  distinction  between 
cartilaginous  separation  and  fracture  of  the  bone,  the  sur- 
geon should  state  the  conditions  found  in  the  most  une- 
quivocal way.  If  the  distortion  is  lateral,  it  may  usually 
be  corrected  by  external  manipulations,  simply  remodelling 
the  fragments  into  position.  If  elevation  is  required,  such 
manipulations  may  be  combined  with  pressure  from  within 
by  some  delicate  though  rigid  instrument  introduced  into 
the  nostril.  Once  replaced,  the  fragment  rarely  shows  any 
disposition  to  fall  out;  but  as  union  of  the  nasal  bones 
takes  place  with  extraordinary  rapidity,  no  effort  should  be 
spared  to  accomplish  everything  necessary  in  the  way  of 
adjustment  during  the  first  week,  for  it  is  at  this  time  that 
the    receding    swelling    furnishes    improved    opportunity    to 


23O  A    CLINICAL    TREATISE    OX  FRACTURES. 

note  carefully  the  slightest  remaining  defect,  while  yet  it 
may  be  corrected.  So  important  to  the  individual  is  it 
that  his  nose  should  be  restored  as  nearly  as  possible  to  its 
former  contour,  that  the  surgeon  may  well  be  guided  dur- 
ing this  process  of  remodelling  by  the  patient's  friends 
and  the  patient  himself,  through  the  aid  of  a  mirror.  At 
the  end  of  a  fortnight  no  correction,  except  by  the  exercise 
of  undue  force,   is  possible. 

Treatment. — The  greater  number  of  cases  of  fracture 
of  the  nose  require  no  retaining  appliance.  If  the  fragments 
are  comminuted  and  show  disposition  to  fall  to  one  side, 
sufficient  support  to  retain  them  in  position  can  usually  be 
obtained  by  the  application  of  a  small  compress  applied  to 
that  side  of  the  nose  requiring  pressure,  and  retained  in 
position  by  a  narrow  strip  of  adhesive  plaster  carried  from 
cheek  to  cheek,  with  the  degree  of  firmness  found  neces- 
sary. In  performing  reduction  advantage  may  be  taken  of 
the  local  anaesthetic  effects  of  cocaine.  All  retaining  appli- 
ances introduced  into  the  nostril  or  nostrils  should,  if 
possible,  be  avoided,  for  they  are  extremely  uncomfortable 
to  the  patient  and  are  seldom  required  except  in  cases  in 
which  the  septum  has  been  fractured  in  such  a  way  as  to 
cause  collapse  of  the  nose. 

FRACTURES    OF    THE    UPPER   JAW. 

Fracture  of  the  upper  jaw  is  caused  by  direct  violence 
of  a  severe  degree.  The  body  or  the  nasal  or  the  alveolar 
process  may  be  involved.  Fractures  extending  through  the 
nasal  process  may  or  may  not  implicate  the  lachrymal  canal. 


FRACTURES    OF  BOXES   OF   THE   FACE.  23 1 

The  infra-orbital  nerve  may  be  injured  by  a  fracture  near 
the  orbital  plate.  The  fracture  not  infrequently  involves 
also  the  sphenoid,  nasal,  or  malar  bones;  and  in  general 
crushes  of  the  face  the  upper  jaw  may  be  completely 
detached  from  the  skull. 

In  all  fractures  involving  the  alveolar  process  the  teeth 
of  the  lower  jaw  will  usually  be  found  to  give  sufficient 
support  without  the  employment  of  splints  of  gutta-percha 
or  the  like,  which  have  occasionally  been  used.  Frag- 
ments which  are  depressed  should  be  elevated  if  they  can 
be  reached  through  the  mouth. 

FRACTURES    OF    THE    MALAR    BONE. 

Fractures  of  the  malar  bone  as  single  injuries  are  uncom- 
mon, for,  although  its  position  is  exposed,  its  structure  is 
so  compact  that  it  either  resists  violent  impacts  or  transmits 
their  force  to  an  adjacent  bone.  They  may  be  simply 
fissures,  or  they  may  extend  into  the  antrum,  constituting 
depressed  fractures.  Such  a  fracture  is  reduced,  if  simple 
and  much  depressed,  by  the  employment  of  a  screw-eleva- 
tor inserted  through  a  small  incision  made  in  the  cheek. 
A  line  of  fracture  in  the  malar  bone  may  include  in  its 
course  and  injure  the  infra-orbital  branch  of  the  fifth  pair 
of  nerves,  producing  loss  of  sensation  of  portions  of  the 
face,  as  the  alse  of  the  nose,  gums,  and  teeth  of  the  upper 
jaw. 

The  treatment,  after  reduction  of  any  displaced  frag- 
ments, is  to  keep  them  in  proper  position  by  compresses 
applied   with    adhesive    strips,    and    to    relieve    the    severe 


232  A    CLINICAL    TREATISE    OX  FRACTURES. 

accompanying  contusion  of   the  cheek  by  cold  evaporating 
lotions. 

FRACTURE    OF    THE    ZYGOMA. 

The  zygoma,  a  strong  arch  in  construction,  is  seldom 
broken  except  by  some  concentrated  force  applied  directly 
to  it.  The  temporal  portion  is  more  apt  to  suffer,  as  it  is 
lighter  and  more  exposed  than  the  malar.  A  fragment  may 
press  upon  the  masseter  or  temporal  muscles,  causing  pain 
on  movement  of  the  jaw.  If  markedly  depressed,  it  may  be 
necessary  to  elevate  the  fragment  with  a  loop  of  wire  passed 
beneath  it  through  a  small  incision  in  the  skin.  Application 
of  Barton's  bandage  to  restrict  the  movements  of  the  lower 
jaw  is  the  simple  treatment  required  for  the  fracture. 

FRACTURES    OF    THE    LOWER   JAW. 

While  any  portion  of  the  lower  jaw  is  liable  to  fracture 
— body,  ramus,  coronoid  process,  or  condyloid  process — that 
portion  of  the  body  from  its  middle  forward  to  its  sym- 
physis is  much  the  most  frequent  seat  of  fracture.  The 
condyloid  process  may  be  fractured  in  its  neck  by  force  com- 
municated through  the  length  of  the  bone  from  the  chin; 
but  fracture  of  the  coronoid  process  is  extremely  rare.  The 
ramus,  though  more  commonly  broken  than  either  of  these 
processes,  is  far  less  frequently  fractured  than  the  body. 
Double  fractures  of  the  body  of  the  jaw  are  not  uncom- 
mon. Fractures  of  the  body  are  almost  invariably  com- 
pound through  their  communication  with  the  mouth. 

Symptoms  of  fracture  of  the  lower  jaw  after  a  severe 
blow  applied  directly  in  front  or  at  its  side  are  pain  on  the 


FRACTURES   OF  BONES    OF   THE   FACE.  233 

slightest  movement,  and  profuse  salivation,  with  more  or 
less  loss  of  the  natural  contour  of  the  lower  portion  of  the 
face.  If  no  pronounced  deformity  exists  externally,  inspec- 
tion of  the  mouth  will  usually  show  an  abrupt  break  in  the 
line  of  the  teeth  at  a  point  corresponding  to  the  seat  of 
fracture.  Crepitus  can,  as  a  rule,  be  easily  elicited.  Ante- 
rior to  the  insertion  of  the  masseter  near  the  dental  fora- 
men, the  anterior  fragment  may  be  drawn  inwards  by  the 
action  of  the  digastric  muscle,  while  the  internal  pterygoid 
and  deep  masseter  tend  to  act  more  or  less  upon  the  pos- 
terior fragment.  The  deformity  from  fracture  at  any  por- 
tion of  the  body  is  variable,  and  often  not  very  great.  Should 
the  fracture  involve  the  alveolar  process  only,  obviously  no 
change  in  exterior  contour  of  the  jaw  occurs.  Fracture  of 
the  condyloid  process  through  its  neck  causes  great  pain  on 
movement  of  the  jaw  and  crepitus  can  usually  be  elicited. 
Treatment  of  Fracture  of  the  Lower  Jaw. — 
There  are  two  distinct  methods  of  treatment  which  may  be 
used  alone  or  in  combination :  (a)  the  external  method, 
which,  of  course,  includes  every  form  of  dressing  and  splint 
applied  to  the  face ;  and  (b)  the  internal  method,  which 
consists  in  retaining  the  fragments  in  apposition  by  various 
devices  employed  in  the  mouth.  As  the  teeth  of  the  upper 
and  lower  jaws  when  fairly  intact  meet  with  nice  precision, 
they  will  usually  be  found  in  a  well-formed  jaw  to  give  the 
required  opposing  resistance  to  the  pressure  of  an  external 
dressing.  It  will,  as  a  rule,  be  found  that  when  a  fracture 
in  any  portion  of  the  body  of  the  jaw  is  properly  reduced 
the  teeth  will  fit  accurately.     In  accomplishing  this  reduc- 


234  A    CLINICAL    TREATISE    ON  FRACTURES. 

tion,  therefore,  the  patient's  sensations  will  frequently  be 
found  of  assistance.  Such  reduction  is  effected  by  simply 
grasping  the  fragments  with  the  fingers  and  thumbs  and 
coaxing  them  into  proper  position.  This  done,  the  lower 
jaw  is  closed  and  the  chin  supported,  during  the  applica- 
tion of  a  Barton  bandage.  As  the  action  of  the  Barton 
bandage  is  symmetrical,  elevating  and  receding  the  jaw 
equally  on  both  sides,  it  will  occasionally  be  found  that 
a  more  unilateral  support  given  by  the  oblique  bandage 
of  the  face  will  better  correct  a  tendency  to  recurrence  of 
the  deformity.  Again,  if  the  anterior  chin-turn  of  Barton's 
bandage,  by  causing  overlapping  of  fractured  fragments, 
is  found  to  induce  too  much  recession  of  the  chin,  a  Gibson 
bandage,  without  the  third  ellipse,  is  available.  With  one 
or  other  of  these  dressings  almost  every  case  of  fracture  of 
the  jaw  can  be  satisfactorily  managed,  but  no  rule  can  be 
made  regarding  the  particular  fracture  to  which  each  is 
applicable,  as  the  advantage  of  either  in  any  individual 
case  can  best  be  determined  by  experiment.  As  salivation 
is  profuse,  any  dressing  becomes  quickly  saturated,  and 
should  therefore  be  frequently  removed  during  the  early 
part  of  the  treatment,  the  skin  of  the  face  carefully  bathed 
with  alcohol,  the  hair  of  the  head  brushed  and  combed, 
and  a  new  bandage  applied.  On  account  of  the  salivary 
overflow  and  the  fact  that  the  mouth,  imperfectly  cleansed, 
inclines  to  become  foul,  any  permanent  leather  or  muslin 
sling  or  splint,  of  which  many  have  been  devised,  is  very 
undesirable.  In  order  to  prevent  putrefaction  resulting, 
partly  from  retained  food-products  and  partly  from  suppura- 


FRACTURES   OF  BONES   OF   THE   FACE.  235 

tion  at  the  seat  of  fracture,  the  mouth  should  be  thoroughly 
rinsed  out  after  each  meal  with  a  potassium  chlorate  solution, 
peroxide  of  hydrogen  freely  atomized  into  it  and  flushed 
out  with  plain  water. 

Should  the  dressings  applied  fail  to  retain  the  fragments 
in  proper  position,  either  because  the  teeth  are  imperfect 
or  because  the  fragments  are  refractory,  coaptation  may  be 
facilitated  by  some  internal  method.  An  interdental  splint 
may  be  made  of  gutta-percha  softened  in  hot  water  and 
modelled  into  the  form  of  a  horseshoe.  On  insertion  in  the 
mouth  the  teeth  of  the  lower  jaw  are  brought  up  firmly,  in 
order  to  mould  it  into  form.  Such  a  splint  had  best  be 
prepared  by  a  dentist,  if  used  at  all.  It  is  extremely 
uncomfortable,  and  must  rarely  be  required.  The  two  teeth 
adjacent  to  the  fracture  may  be  conjoined  by  a  silver  wire; 
or,  if  the  fracture  involve  one  alveolus,  the  tooth  loosened 
thereby  may  have  to  be  extracted  and  the  adjoining  teeth 
wired  together.  During  the  first  two  weeks  of  treatment 
the  patient  should  be  nourished  almost  wholly  with  liquid 
food ;  milk,  soups,  and  soft-boiled  eggs  being  among  the 
most  useful  articles  of  diet.  Union  firm  enough  not  to 
require  support  usually  occurs  between  the  fourteenth  and 
twentieth  days,  but  no  effort  should  be  made  at  mastica- 
tion, until  the  end  of  four  weeks.  Delayed  union  and 
ununited  fracture  of  the  lower  jaw  are  very  rare. 

Barton's  bandage  when  used  for  fracture  of  the  lower  jaw 
should  be  applied  as  follows:  Place  the  initial  extremity  of 
the  roller  behind  the  ear  on  the  sound  side;  carry  the  roller 
beneath    the   occiput  to  a  corresponding  point   behind   the 


236  A    CLINICAL    TREATISE    ON  FRACTURES. 

ear  on  the  injured  side;  thence  to  the  vertex,  and  down  the 
sound  side  of  the  face  to  the  chin;  up  on  the  injured  side 
to  the  vertex,  intersecting  the  former  turn  directly  in  the 
median  line,  and  back  to  the  starting-point.  Not  until 
then  is  the  bandage  fixed.  The  fingers  holding  the  initial 
extremity  are  now  released,  and  the  roller  may  be  conven- 
iently passed  from  one  hand  to  the  other.  The  roller 
passes  from  here  to  the  occiput,  and  along  the  injured  side 
of  the  jaw  to  the  chin,  and  back  to  the  occiput;  from  the 
occiput  to  the  vertex.  Each  of  these  turns  is  repeated  in 
a  similar  manner  twice,  when  the  bandage  is  terminated 
at  the  vertex.  Every  intersection  requires  a  pin.  Gibson's 
bandage  is  applied  in  the  following  manner :  Fix  the  roller 
by  vertical  turns  around  the  face.  The  direction  it  takes 
in  starting  '  is  determined  by  the  location  of  the  fracture, 
the  roller  always  ascending  on  the  injured  side.  After 
making  three  of  these  vertical  turns  a  right-angled  reverse 
is  made  at  the  temple,  on  whichever  side  is  more  conven- 
ient, and  the  bandage  carried  back  to  the  occiput.  Three 
horizontal  turns  are  then  made  around  the  vault  of  the 
cranium,  and  on  reaching  the  occiput  the  third  time  the 
chin-turns  are  begun.  These  are  made  by  carrying  the 
roller  beneath  the  ear,  along  the  side  of  the  jaw  to  the 
front  of  the  chin,  and  back  to  the  occiput.  Three  of 
these  turns  are  made.  On  reaching  the  occiput  the  third 
time  the  bandage  is  completed  by  a  right-angled  reverse 
at  this  point,  whence  it  is  carried  over  the  top  of  the 
head  to  the  forehead  in  the  median  line.  A  pin  is 
introduced    at   the   reverse   over    the   occiput,    and   at   each 


FRACTURES    OF  BOXES    OF   THE   FACE.  237 

intersection.     It  will   be   seen    to    consist   of  three   sets    of 
circular  turns. 

FRACTURES  OF  THE  HYOID  BONE. 

The  hyoid  bone  is  occasionally  fractured  from  constric- 
tion, as  in  hanging  or  throttling,  and  even  by  direct  im- 
pact, as  from  a  fall  or  a  blow  upon  the  throat.  There  is 
pain,  increased  by  deglutition  or  articulation,  but  respiration 
may  be  so  embarrassed  that  every  symptom  of  fracture  is 
masked  by  the  alarming  dypncea,  which  threatens  instan- 
taneous suffocation.  Immediate  tracheotomy  may  therefore 
be  necessary  to  save  life  before  an  attempt  is  made  either  to 
examine  into  the  nature  of  the  injury  or  to  reduce  any  dis- 
placement which  may  be  found  to  exist.  Tracheotomy  may 
also  be  indicated  as  a  precautionary  measure  to  guard  against 
the  imminent  danger  of  inflammatory  oedema  suddenly  ex- 
tending to  the  glottis. 

The  management  of  the  fracture,  which  is  of  secondary 
importance,  consists  in  correcting  any  displacement  of  the 
fragments  with  a  finger  introduced  into  the  pharynx,  and  in 
keeping  the  head  at  rest  in  a  state  of  moderate  flexion.  For 
the  first  few  days,  or  while  local  irritation  and  muscular 
spasm  continue,  no  food  should  be  given  by  the  mouth,  nu- 
tritious enemata  being  onlv  used. 


CHAPTER    IX. 
COMPOUND    FRACTURES. 

The  compound  element  of  a  fracture — i.  e.,  the  presence 
of  an  external  wound  communicating  with  the  seat  of  fract- 
ure— while  it  always  tends  to  increase  the  gravity  of  the 
injury,  does  so  now,  with  the  present  perfection  of  surgical 
technique,  far  less  than  formerly.  A  larger  proportion  of 
compound  fractures  are  susceptible  of  conversion  into  sim- 
ple fractures  with  thorough  asepsis;  and  those  which  do 
suppurate,  suppurate  so  slightly  and  are  so  free  from  infec- 
tion that,  while  the  course  of  the  injury  is  somewhat 
retarded  by  the  compound  element,  its  termination  is  seldom 
jeopardized. 

For  convenience  of  description,  the  wound  communicat- 
ing with  the  seat  of  fracture  may  be  called  the  compound 
wound.  The  compound  wound  is  produced  (a)  externally 
bv  the  bodv  causing  the  fracture  or  (b)  by  one  of  the  frag- 
ments of  the  fractured  bone  being  driven  through  the 
integument,  (a)  When  the  compound  wound  is  produced 
bv  external  violence  its  presence  may  depend  wholly  upon 
so  casual  an  incident  as  the  absence  of  protection  afforded 
bv  clothing,  as  in  the  passage  of  a  wagon-wheel  over  a 
limb  which  is  bare.  The  force  exerted  is  no  greater  than 
if  clothing  had  intervened,  and  the  wound  is  made  by  the 
harsh  pressure  of  the  integument  between  metal  and  bone. 

238 


COMPOUND   FRACTURES.  239 

In  like  manner,  of  two  wagons  of  equal  weight,  the  one 
provided  with  steel,  the  other  with  rubber  tires,  the  former 
may  in  passing  over  a  limb  cause  a  compound,  the  latter 
a  simple  fracture.  Compound  fracture  caused  in  this  way 
results  also  from  railroad,  machinery,  and  all  other  injuries 
in  which  the  compound  element  is  produced  directly  by 
the  vulnerating  body.  Such  may  therefore  well  be  called 
a  direct  compound  fracture,  not  only  because  of  the  man- 
ner of  its  production,  but  also  because  in  it  the  wound  is 
usually  situated  immediately  over  the  seat  of  fracture  and 
gives  direct  communication  between  the  latter  and  the 
exterior,  {b)  If,  on  the  other  hand,  the  compound  wound 
is  made  by  a  fragment  of  bone  (usually  the  upper)  being 
thrust  through  the  skin,  investigation  of  the  cause  will 
show  it  to  have  been  indirect  violence,  and  the  compound 
wound  will  likely  be  more  or  less  remote  from  the  seat  of 
fracture.  It  may,  therefore,  be  appropriately  described  as 
an  indirect  compotmd  fracture.  Its  presence  indicates  that 
the  force  causing  the  fracture  had  not  ceased  with  the 
production  of  the  latter,  but  had  gone  on  thrusting  the 
broken  fragment  out  through  the  skin,  wounding  in  its 
course  the  intervening  tissues  to  its  point  of  emergence. 
It  is,  therefore,  the  continuance  of  the  breaking  force, 
after  the  bone  has  yielded,  which  renders  damage  to  blood- 
vessels, nerves,  and  muscles  more  liable  to  occur  in  com- 
pound fractures  so  produced  than  in  simple.  In  the  same 
way,  voluntary  or  involuntary  muscular  contraction  or  care- 
less handling  may  convert  a  simple,  into  a  compound 
fracture,  by  forcing  the  upper  fragment  of  the  bone  through 


24O  A    CLINICAL    TREATISE    ON  FRACTURES. 

the  integument.  When  this  happens  the  cause  is  identical 
with  that  producing  compound  fracture  by  the  continu- 
ance of  the  force  after  the  bone  has  yielded.  The  char- 
acter of  the  fracture,  whether  transverse  or  oblique,  and  the 
form  of  the  penetrating  fragment,  whether  sharp  and  pointed 
or  smooth  and  blunt,  will  determine  the  extent  and  nature 
of  the  wound  produced.  As  fractures  caused  by  indirect 
violence  incline  to  be  oblique,  and  as  force  thus  indirectly 
applied  is  of  a  kind  most  liable  to  thrust  a  fragment  of 
bone  through  the  skin,  the  fragment  exposed  is  frequently 
the  more  or  less  slender  extremity  of  an  oblique  fracture. 

Compound  fractures  are  frequently  more  difficult  to  re- 
duce and  to  keep  reduced  than  simple  fractures,  for  three 
reasons :  (1)  The  fractured  ends  of  the  bone  may  be  com- 
minuted or  bruised  by  the  crushing  force,  as  of  a  car-wheel, 
which  has  produced  the  injury,  and  has  so  distorted  the 
surfaces  that  they  cannot  be  refitted  to  one  another.  (2)  In 
fractures  caused  by  indirect  violence  the  surrounding  tissues 
may  be  so  generally  torn  that  they  cannot  give  even  the 
partial  support  to  the  broken  fragments  they  would  do 
under  less  extreme  conditions.  Such  complete  tearing  of 
periosteum,  tendinous,  and  muscular  tissue,  is  more  fre- 
quently observed  in  indirect  compound  fractures,  because  in 
them,  through  the  continuance  of  the  force  after  the  bone 
has  yielded,  one  fragment  is  thrust  far  beyond  the  other 
and  extruded  through  the  skin.  (3)  Proper  reduction  may 
be  prevented  by  the  interposition  between  the  fragments  dur- 
ing their  wide  separation  of  some  portion  of  muscle  or  of  a 
tendon.     The  button-holing  of  the  skin  by  the  protruding 


COMPOUND   FRACTURES.  24 1 

fragment  rarely  offers  any  great  impediment  to  its  reduction. 
The  three  conditions  just  mentioned  existing  separately  or 
in  combination  constitute  the  difficulties  most  frequently 
met  with,  and  to  them  is  often  added  muscular  spasm  from 
severe  traumatic  irritation.  Once  reduced,  it  may  be  found 
impossible  to  retain  the  fragments  in  position  because  of 
their  battered  extremities,  or  of  the  interposition  of  some 
tissue  between  them.  While,  therefore,  efforts  at  reduction 
of  simple  fractures  rarely  fail,  compound  fractures  of  cer- 
tain bones  are  often  difficult  to  adjust  without  the  aid 
of  some  mechanical  device  having  more  direct  action 
than  can  be  obtained  by  the  employment  of  splints  or 
apparatus. 

Apart  from  the  bone  lesion,  compound  fractures  are  fol- 
lowed by  more  or  less  suppuration,  the  degree  of  which 
depends  (1)  upon  the  extent  of  damage  done  the  soft  parts 
by  the  injury,  (2)  the  completeness  of  the  surgical  procedure 
in  preventing  infection,  (3)  the  presence  or  absence  at  the 
seat  of  fracture  of  any  material  acting  as  an  irritant,  and 
(4)  the  perfection  of  the  immobility  of  the  fractured  frag- 
ments obtained. 

1.  Pulpefied  soft  tissue,  having  been  completely  devital- 
ized by  the  injury,  necessarily  becomes  necrotic,  and  must 
be  detached  from  the  living  by  a  process  which  involves 
suppuration.  Properly  supervised,  this  process  may  be 
conducted  without  risk  of  the  infection  of  the  living  tissue 
by  the  dead.  At  times  dead  tissue  may  be  reduced  by  such 
an  agent  as  plaster-of-Paris  to  a  desiccated,  mummified  con- 
dition and  the  ulcerative  process  thereby  minimized. 

16 


242 


A    CLINICAL    TREATISE    ON  FRACTURES. 


Fig.  113. 


2.  The  importance  of  surgical  cleanliness  in  preventing 
infection  and  consequent  suppuration  can  best  be  emphasized 
by  a  brief  retrospect  of  the  clinical 
history  of  compound  fractures  in  the 
preaseptic  period.  Fig.  113  shows  the 
results  of  a  septic  osteitis  of  the  tibia 
and  fibula  following  compound  fract- 
ure, and  strikingly  illustrates  the  dis- 
astrous course  which  unhappily  too 
often  followed  the  injury.  As  no 
sterilization  was  thought  of,  septic 
suppuration  in  almost  every  case  fol- 
lowed. As  the  true  principles  of 
mM  drainage    were    not     understood,     pus 

burrowed.       Following  the   routes   of 
least  resistance,    it   found  its  way  be- 
( I       :  ,  neath     the    superficial     fascia    in    all 

c    ..      .  ...  ^^  „     directions,  to  the  seat  of  fracture,  and 

Septic  osteitis  accompanying  '  ' 

compound  fracture  of  the     {n\_Q  the  medullary  cavity  of  the  bone. 

tibia  and  fibula.  .  ,,.,., 

Being  septic,  it  decomposed  healthy 
tissue  by  contact,  and  so  increased  its  own  bulk.  Com- 
pound fractures  discharged  pus  so  copiously  that  Barton 
utilized  the  bibulous  properties  of  bran  to  absorb  it,  and 
for  nearly  forty  years  the  bran  dressing  was  almost  exclu- 
sively employed  in  certain  localities.  The  advantages 
claimed  for  it  were  that  when  thoroughly  saturated  with 
pus  it  swelled  somewhat  and  gave  good  support  to  the 
limb,  that  it  prevented  the  pus  overflowing  into  the  bed 
clothes,    and    that   the    dressing   was   quickly    changed    by 


COMPOUXD   FRACTURES.  243 

letting  fall  the  sides  of  the  fracture-box,  scooping  up  the 
soaked  portion  of  bran  with  both  hands  and  pouring  in 
fresh  from  a  bucket.  The  only  reduction  attempted  was 
that  by  manipulation  and  the  adjustment  of  splints,  for 
the  dangers  of  operation  were  known  to  be  so  great  that 
it  was  rarely  undertaken,  and  refractory  fragments  there- 
fore remained  often  very  imperfectly  coaptated.  The  lesson 
therefore  tausfht  is  that  no  detail  of  cleanliness  or  drainage, 
no  detail  of  reduction  or  coaptation,  nor  of  fixation,  can 
be  slighted  without  risk  of  trouble. 

3.  The  presence  at  the  seat  of  fracture  of  any  material 
acting  as  an  irritant,  either  because  it  is  a  focus  for  infec- 
tion or  is  a  foreign  body,  promotes  suppuration  until  it  is 
discharged,  or,  remaining  at  the  seat  of  fracture,  ma}"  indefi- 
nitely prolong  the  process.  The  former  is  often  produced 
bv  foreign  matter  which  gained  access  to  the  wound  at  the 
time  of  the  injury.  The  latter,  though  occasionally  a  real 
foreign  body,  is  more  frequently  a  comminuted  fragment 
of  bone  which,  having  been  detached,  has  become  necrotic 
and  acts  as  such. 

4.  The  perfection  of  immobility  attained  at  the  seat  of 
fracture  markedly  influences  the  degree  of  suppuration.  The 
importance  of  complete  fixation,  therefore,  in  compound 
fractures  adds  this  to  the  other  advantages  obtained  by  it. 

Complications. — General  conditions  which,  by  adding 
gravity  to  a  compound  fracture,  may  well  be  considered  as 
complications,  relate  to  the  age  and  health  of  the  patient, 
and  to  what  is  to  be  his  surgical  environment  during  the 
course  of  treatment. 


244  A    CLIXICAL    TREATISE    OX  ERACTURES. 

Thus  a  vouthful  individual  of  sound  and  vigorous  health 
and  temperate  habits  receiving  a  compound  fracture  is 
promptlv  removed  to  a  suitable  place  for  treatment. 
Whether  his  injury  be  slight  or  grave,  it  is  at  least  attended 
by  no  general  complication  of  any  sort.  Any  deviation 
constitutes  a  drawback,  and  may  prove  sufficiently  serious 
to  change  radically  the  whole  aspect  of  the  case,  and,  later, 
the  treatment  it  requires.  Thus,  the  hope  of  saving  a 
limb  may  be  wholly  negatived  on  account  of  the  advanced 
age  of  the  patient  or  the  presence  of  visceral  disease.  The 
great  importance  of  prompt  and  suitable  management  is 
well  illustrated  by  the  unfortunate  necessity  in  war  of 
amputating  many  compound  fractures  in  order  to  diminish 
the  risk  to  life  in  preparing  for  a  long  journey,  because  a 
case  of  amputation  can  be  subjected  to  greater  hardships  in 
travelling  by  land  or  sea,  consistently  with  life,  than  can 
a  suppurating  compound  fracture. 

Specific  and  local  complications  are  :  ( i)  Comminution. 
Comminution  of  the  bone  adds  to  the  gravity  of  compound 
fracture  in  many  respects.  It  usually  indicates  that  greater 
force  has  produced  the  injury  than  that  required  to  cause 
a  single  line  of  fracture.  It  leaves  fragments  of  bone  which 
are  liable  to  become  necrotic  (Fig.  114).  Also  such  fracture, 
if  it  suppurates,  requires  more  care  to  keep  properly  drained 
and  cleansed,  and,  owing  to  its  great  mobility,  complete  fixa- 
tion of  the  fragments  is  more  difficult  to  obtain.  (2)  Joint- 
involvement  always  increases  the  severity  of  a  compound 
fracture.  It  does  so  at  once  by  embarrassing  reduction,  by 
increasing  the  tendency  to  suppuration,  and  by  opening  up 


COMPOUND   FRACTURES.  245 

a  dangerous  pocket  for  infection ;  and  it  does  so,  finally,  by 
causing  rigidity  of  the  joint  involved.  (3)  The  tearing  of 
an  arterial  trunk  often  decides  adversely  the  fate  of  the 
limb  in  many  compound  fractures  which  would  otherwise 
yield  successfully  to  conservative  means.  Such  a  compli- 
cation as  applied  to  the  femoral  or  brachial  artery  almost 
inevitably  turns   the   scale,   but   this   is   by  no  means   true 

Fig.  114. 


Compound  fracture  of  the  femur  with  comminution  and  subsequent  necrosis  of  the 
large  middle  fragment. 

when  only  one  artery  is  wounded  in  portions  of  the  limb 
which  are  supplied  by  more  than  one  trunk.  (4)  Injury 
to  a  nerve,  while  it  renders  the  prognosis  of  ultimate 
restoration  of  function  of  the  limb  sometimes  doubtful, 
does  not  add  materially  to  the  difficulties  to  be  met  with 
during  treatment,  especially  if  it  be  only  wounded,  not  sev- 
ered. (5)  Injury  to  the  soft  parts,  either  extensive  laceration 
of  the    integument   which   denudes   a   considerable   portion 


246  A    CLINICAL    TREATISE    ON  FRACTURES. 

of  the  limb,  particularly  if  girdling  it,  on  the  one  hand,  or 
perhaps  only  minute  puncture  of  the  skin,  accompanied  by 
severe  bruising  or  pulpefaction  of  the  muscles,  effectually 
disposes  of  any  opportunity  for  conservatism.  Should  ampu- 
tation be  advised  and  refused,  it  remains  for  the  surgeon 
to  decide  in  each  individual  case  whether  he  should  simply 
cleanse  the  wound,  provide  for  suitable  drainage,  and 
retain  the  limb  at  rest  with  an  appropriate  splint,  or 
whether  he  should  operate  upon  the  damaged  bone.  With- 
out discussing  the  numerous  aspects  of  this  subject,  it  may 
be  stated  in  general  terms  that  it  is  probably  desirable  in 
certain  cases  of  compound  fracture  regarded  as  hopeless,  in 
which  amputation  has  been  refused,  to  anaesthetize  the 
patient  and  do  what  would  be  done  were  it  hoped  or  intended 
to  have  saved  the  limb. 

The  degree  of  shock  after  compound  fracture  varies  very 
much,  and  though,  as  a  rule,  it  is  in  proportion  to  the 
gravity  of  the  injury  and  the  loss  of  blood,  yet  it  often 
depends  largely  upon  the  individual  lack  of  resistance  of 
the  patient.  While  it  is  usually  possible  to  discriminate 
between  temporary  emotional  shock  and  the  severe  consti- 
tutional shock  accompanying  a  grave  injury,  the  psychical 
element  will  often  be  observed  to  retard  reaction. 

Tetanus. — Formerly  not  infrequent  among  the  fatal 
consequences  of  compound  fracture,  tetanus  has  happily, 
through  aseptic  methods,  become  rare.  It  followed,  and 
even  under  these  improved  methods  may  occasionally  fol- 
low, compound  fractures,  either  those  usually  considered 
insignificant,  as  of  the  bones  of  the  hand  and  foot,  or  those 


COMPOUND   FRACTURES.  247 

which   are   grave.     Its  occurrence   is  more  to  be  feared  if 
there  has  been  much  comminution  of  bone  accompanied  by 
great  laceration  or  crushing  of    the  soft  parts.     As  dirt— 
that  is,  either  city  dirt  or  country  dirt— is  liable  to  contain 
tetanus  bacilli,   and  as  dirt  has  often  gained  access  to  the 
most  intricate  recesses  of  the  bone,  soft  tissues,  or  a  joint, 
the  possible  risk  of  tetanus  is  one  of  the  complications  to 
be  borne  in  mind  when  conducting  the  sterilizing  process 
before    the   application    of  the   first   dressing.     If  the  com- 
pound fracture  has  been  caused  by  the  passage  of  a  wheel 
over  the  part,  dirt  is  ground  into  the  wound  and  often  into 
the  bone;  or,  if  a  bone  be  fractured  by  a  fall  and  the  upper 
fragment  is  thrust  through  the  skin  into  the  ground,   the 
fractured   fragment   may  be  filled  with  dirt,   which  can  be 
completely    removed    only   by    the   most    careful    cleansing, 
combined,   if  necessary,   with  scraping  or  cutting.     Should 
tetanus    ensue,    the   operative  procedures   offering  a  chance 
of  recovery  are  stretching  of  the  nerve-trunk  supplying  the 
part,  or,   if  the  injury  involves  a  finger  or  toe,  amputation. 

Fat-embolism  is  an  extremely  grave,  but  fortunately 
rare,  complication  of  compound  fracture.  It  is  due  to  small 
particles  of  liquid  fat  from  the  bone-marrow  entering  the 
venous  circulation,  and  usually  does  not  manifest  itself 
until  three  or  four  days  subsequent  to  the  fracture  of  the 
bone.  The  symptoms  develop  with  considerable  sudden- 
ness, the  most  prominent  being  disturbance  of  respiration 
and  of  the  heart's  action.  There  is  usually  great  dyspnoea, 
and  the  respiration  becomes  Cheyne-Stokes  in  character. 
The  temperature  is  elevated,  fat-globules  are  liable  to  appear 


248  A    CLINICAL    TREATISE    ON  FRACTURES. 

in  the  urine,  and  occasionally  there  is  paralysis  of  various 
groups  of  muscles.  The  treatment  of  such  a  condition  is 
entirely  symptomatic,  chiefly  consisting  in  the  rigorous  use 
of  rapidly  acting  and  powerful  cardiac  and  respiratory 
stimulants.  Amputation  of  the  fractured  limb  has  been 
advocated  in  order  to  prevent  the  danger  of  further  forma- 
tion of  emboli,  but,  in  the  presence  of  cardiac  and  respira- 
tory disturbances,   it  could  not  be  undertaken. 

Gangrene  following  compound  fracture  results  from 
deficiency  in  the  blood-supply  produced  by  injury  of  a 
principal  arterial  trunk  or  by  the  mechanical  interference 
with  circulation  of  overdistended  and  engorged  tissues. 
Either  is  capable  of  causing  gangrene,  though  they  may 
act  in  combination  as  when  even  moderate  tension  succeeds 
ligation  of  the  posterior  tibial  artery  in  a  compound  fracture 
of  the  leg.  The  collateral  circulation,  which  would  quickly 
and  surely  be  established  after  simple  ligation,  is  prevented 
by  tissue  tension,  and  gangrene  results.  In  a  subject  with 
diabetes  or  atheroma  very  slight  tissue  tension  will,  after 
compound  fracture,  cause  gangrene. 

Treatment. — Compound  fracture  belongs  to  the  class 
of  injuries  which  cannot  receive  too  prompt  surgical  atten- 
tion. If  seen  as  an  emergency,  it  is  better  to  cover  the 
wound  with  a  clean  handkerchief  or  napkin  than  to  con- 
duct any  imperfect  efforts  at  washing  or  irrigating  it,  for 
such  measures  done  hastily  may  frequently  do  more  harm 
than  good,  as  they  fail  to  render  the  depths  of  the  wound 
sterile  and  are  very  likely  to  convey  infection  into  it.  In 
order  to  keep  the  fragments  of  bone  as  quiet  as  possible, 


COMPOUND   FRACTURES.  249 

an  extemporized  splint  may  be  applied.  When  the  patient 
has  reached  his  destination — that  is,  the  hospital  or  house 
at  which  he  is  to  be  treated — preparations  should  be  quickly 
but  methodically  made  for  the  first,  the  all-important 
dressing. 

If  any  indications  exist  that  the  wound  will  have  to 
be  enlarged,  that  the  fragments  of  bone  will  be  at  all  refrac- 
tory in  yielding  to  adjustment,  that  they  may  require  con- 
trolling, sawing,  or  suturing,  that  a  bloodvessel  will  have 
to  be  tied,  or,  finally,  if  the  patient  is  already  suffering 
much  pain  or  agitation,  an  anaesthetic  should,  without  hesi- 
tation, be  administered.  With  instruments  and  appliances 
appropriate  for  wound-dressing,  bone-joining,  and  amputa- 
tion made  ready,  the  temporary  dressing,  if  one  has  been 
employed,  is  removed  and  the  skin  shaved  over  a  liberal 
area  about  the  wound.  The  latter  is  freely  irrigated  with  a 
1  :  2000  solution  of  corrosive  sublimate  and  the  adjacent 
skin  sterilized.  Not  until  then  is  a  systematic  exploration 
made  of  the  damage  done  and  a  decision  reached  of  the 
steps  necessary  to  be  taken.  As  the  compound  wound  may 
vary  in  size  from  a  minute  puncture  to  an  extensive  lacera- 
tion, the  question  whether  to  allow  it  to  remain  as  it  is  or 
to  enlarge  it  sufficiently  to  admit  the  entrance  of  a  finger 
must  rest  wholly  upon  the  conditions  observed.  Should 
there  be  little  tendency  to  displacement  of  fragments,  and 
the  tissue  beneath  feel  comparatively  soft  and  relaxed,  if 
the  skin  is  pale  and  pliable,  and  little  or  no  blood  oozes 
from  the  wound,  it  should  not  be  opened.  Indeed,  under 
circumstances  in  which  it  may  fairly  be  assumed  that  the 


250  A    CLINICAL    TREATISE    ON  FRACTURES. 

minute  puncture  was  made  by  the  pointed  summit  of  a 
fragment  which,  having  penetrated  the  integument,  was  in- 
stantly withdrawn,  even  irrigation  may  be  undesirable,  and 
such  a  wound  may  be  dressed  with  dry  sterile  gauze.  Seal- 
ing it  with  tincture  of  benzoin  or  collodion,  while  still 
practised,  would  seem  to  have  no  advantage  over  dry  gauze 
dressing  in  favoring  its  early  closure,  and  the  conversion 
thereby  of  the  compound  into  a  simple  fracture.  The  prog- 
ress of  such  cases,  whether  occurring  in  the  upper  or  lower 
extremity  often  varies  but  little  from  that  of  a  simple  fract- 
ure. There  may  be  no  suppuration,  and  the  wound  when 
the  dressing  is  removed  at  the  end  of  five  days  or  a  week 
is  found  to  be  closed  ;  or,  superficial  suppuration  of  integ- 
ument may  continue  for  a  fortnight  or  three  weeks  with- 
out any  communication  whatever  with  the  seat  of  fracture. 
In  either  case  the  fracture  unites  in  all  respects  as  does  a 
simple  fracture.  The  compound  element  having  existed 
but  a  brief  period  complicates  the  management  of  the  case 
no  more  than  would  a  wound  of  the  integument  which 
never  did  communicate  with  the  seat  of  fracture.  Such  a 
wound,  like  a  severe  abrasion  or  a  splint-sore,  would  be 
troublesome  only  in  requiring  the  removal  of  the  dressing 
more  frequently  than  necessary  for  the  management  of  the 
fracture.  The  appropriate  splint  or  dressing  for  such  a 
compound  fracture  is  identical  with  that  for  the  fracture, 
had   it   been   simple. 

On  the  other  hand,  if  accompanying  a  minute  wound 
there  be  marked  displacement  or  comminution  of  the  frag- 
ments,    tension    of    the    limb,     or    bogginess    beneath    the 


COMPOUND   FRACTURES.  25  I 

integument,  if  the  skin  be  red,  turgid,  and  tense,  or 
there  is  blood  oozing  from  the  wound  or  a  clot  plugging  it, 
the  wound  should  be  enlarged.  An  incision  large  enough 
to  admit  a  finger  for  exploration  should  at  first  be  made, 
and  afterwards  enlarged  as  the  requirements  demand. 
Should  the  tissue  beneath  be  found  filled  with  blood,  the 
wound  of  an  arterial  trunk  will  be  suspected,  and  its  exist- 
ence will  be  at  once  proved  or  not  by  feeling  for  the  pulsa- 
tion of  the  vessel  involved,  whether  the  posterior  tibial, 
dorsalis  pedis,  radial,  or  ulnar.  Should  the  vessel  be  found 
not  to  pulsate  at  the  distal  point  examined,  it  must  be 
immediately  searched  for  in  the  wound  and  ligated.  As 
injury  to  an  artery  is  almost  always  caused  by  a  fragment  of 
the  broken  bone,  the  lesion  in  it  will  usually  be  found 
pretty  close  to  the  point  of  one  fragment  or  the  other. 
If,  on  the  contrarv,  it  be  determined  that  the  bleedine 
arises  from  numerous  small  vessels,  the  clots  should  be 
turned  out  and  perhaps  some  one  or  two  points  secured. 
Blood-clots  enveloping  the  fractured  fragments  have  been 
allowed  to  remain  in  order  to  facilitate,  as  demonstrated 
by  Schede,  early  union,  provided  there  is  good  reason  to 
believe  that  such  clots  are  aseptic.  Cross-tears  or  lacera- 
tions of  the  muscles  may  properly  be  sutured;  or  if  detached 
from  their  origin  and  drawn  down  into  coiled  masses 
lying  in  the  wound,  they  should  be  excised,  as  the  exten- 
sive dissection  required  to  suture  them  to  their  points  of 
origin — perhaps  two-thirds  of  the  length  of  the  limb — 
could  not  properly  be  undertaken.  After  thorough  irriga- 
tion,  a    drainage-tube    should    be    introduced,    either   as    a 


252  A    CLINICAL    TREATISE    OX  FRACTURES. 

single  tube  emerging  from  the  wound,  which  has  been 
sutured  about  it,  or  a  double  tube  entering  at  one  angle 
of  the  wound  and  emerging  at  the  other,  or  a  through- 
and-through  tube  introduced  into  the  wound  and  carried 
through  a  counter-opening  at  the  opposite  side.  The  extent 
of  drainage  is  provided  for  according  to  the  conditions 
found  and  the  prospect  of  slight  or  free  suppuration  ensu- 
ing. A  dry  gauze  dressing  retained  by  a  gauze  bandage, 
and  a  splint  or  apparatus  appropriate  for  the  management 
of  the  fracture  is  applied. 

A  very  useful  fixed  apparatus  for  compound  fractures  of 
the  tibia  is  found  in  the  plaster-of-Paris  dressing,  with  a 
trap-door  cut  into  it  over  the  seat  of  fracture,  which  permits 
access  to  the  wound  if  necessary.  Such  an  arrangement  is 
best  applied  as  follows  :  A  half-inch  band  of  lead  tape,  of  a 
length  equal  to  the  circumference  required  for  the  trap,  is 
formed  into  a  loop  or  ring  by  closing  the  ends  together  with 
a  bit  of  rubber  plaster.  This  is  applied  to  the  limb,  and, 
modelled  into  an  ellipse,  circle,  or  square,  is  held  in  posi- 
tion by  the  initial  flannel  bandage,  which  also  retains  the 
wound-dressing.  The  plaster-of-Paris  dressing  is  then  ap- 
plied, and  after  it  has  set  the  outline  of  the  lead  wall,  being 
distinctly  apparent,  is  cut  down  upon  with  a  penknife,  ex- 
cept at  one  point  which  is  to  act  as  a  hinge,  and  the  lead 
band  removed,  as  shown  in  Fig.  115.  Beneath  the  everted, 
flange-like  edge  of  the  opening  absorbent  cotton  should  be 
inserted  in  order  to  prevent  the  leakage  of  discharge 
between  the  plaster  dressing  and  the  skin.  The  trap  thus 
formed  is  afterwards  kept  in  place  by  a  bandage.      Should 


COMPOUND  FRACTURES.  253 

the  opening  exceed  in  width  one-third  the  circumference 
of  the  limb,  the  dressing  may  be  reinforced  by  strips  of 
tin  laid  at  its  back  during  the  application  of  the  plaster 
bandages. 

The  removal  of  such  a  dressing  may  be  facilitated  by 
preliminary  steps  taken  at  the  time  of  its  application.  A 
strip  of  lead  tape  placed  upon  the  limb  next  to  the  skin 
may  be  cut  down  upon  with  a  penknife,  immediately  the 
plaster  has  set,    and  a  clean   cut   made    through    its  whole 


Fig.  115. 


Fenestrated  plaster-of- Paris  dressing  for  compound  fracture  of  the  leg,  showing  the 

trap-door  opened. 

length,  after  which  the  lead  tape  is  withdrawn.  Or,  better, 
a  vertebrated  brass  chain,  so  constructed  that  when  it  is 
placed  iipon  a  part  prior  to  the  application  of  a  fixed  dress- 
ing it  will,  on  withdrawal,  as  soon  as  the  plaster  has  set, 
leave  behind  it  in  the  latter  a  hollow  longitudinal  ridge. 
This  may  be  readily  divided  by  a  knife  or  plaster  shears  at 
any  time  it  is  desired  to  remove  the  dressing.  An  improve- 
ment on  this  affair  is  an  India-rubber  strip  of  the  form,  on 
cross-section,  of  an  inverted  T,  which  is  used  in  a  similar 
manner. 

The    progress    of    many    cases    of    compound     fracture, 
whether  direct  or  indirect,  is  often  unexpectedly  favorable. 


254 


A    CLIXICAL    TREATISE    OX  FRACTURES. 


At  the  end  of  five  or  six  days  the  escape  of  bloody  serum 
diminishes,  and  in  two  weeks  the  scanty  suppuration  follow- 
ing will  have  almost  ceased.  When  deep  discharge  no  longer 
flows  from  the  drainage-tubes  thev  should  be   removed  and 


Fig.  116. 


Apparatus  for  using  continuous  irrigation. 

the  granulating  surfaces  dressed  with   a   little   gauze  until 
they  have  healed. 

Occasionally  continuous  irrigation  from  such  an  apparatus 
as  is  shown  in  Fig.  116,  with  some  mild  antiseptic  solution, 


COMPOUND  FRACTURES.  255 

especially  in  compound  fractures  of  the  upper  extremity, 
accompanied  by  violent  cellulitis,  will  relieve  pain  and  ten- 
sion,  and   perhaps  will  limit  sloughing. 

If  the  soft  parts  have  been  damaged  so  much  that  a 
portion  of  tissue  adjacent  to  the  fracture  becomes  necrotic, 
thorough  and  frequent  irrigation  with  peroxide  of  hydrogen, 
followed  by  solution  of  corrosive  sublimate,  may,  by  allow- 
ing the  slough  to  separate  without  causing  infection,  prevent 
bone  suppuration.  Should  the  conditions,  however,  not  be 
so  favorable,  deep  and  more  copious  discharge  of  pus, 
accompanied  by  continued  crepitus  of  the  fragments  on 
motion,  will  clearly  indicate  that  the  seat  of  fracture  is 
implicated  in  the  suppurative  process.  In  such  cases  more 
or  less  necrosis  is  to  be  looked  for.  Absolute  fixation  of  the 
fragments,  always  important,  then  becomes  imperative.  I 
have  seen  the  formation  of  pus  from  a  compound  fracture 
reduced  in  the  space  of  forty-eight  hours  to  perhaps  one- 
twentieth  by  the  substitution  of  an  appliance  which  gave 
perfect  fixation  for  one  which  had  not.  This  detail  cannot 
be  too  strongly  impressed,  for  the  cessation  of  suppuration  is 
essential  to  union  of  the  fragments,  while  its  continuance 
not  only  delays  repair,  but  often  by  causing  osteitis,  dissect- 
ing abscess,  and  occasionally  osteomyelitis,  may  prove  the 
first  cause  for  the  ultimate  sacrifice  of  the  limb. 

When  a  compound  fracture  implicates  a  joint,  as  the 
elbow,  wrist,  knee,  or  ankle,  three  courses  are  open  for  its 
management :  drainage,  and  partial  or  formal  excision. 
Simple  drainage  is  applicable  to  many  cases  in  which  there 
is   no   comminution    of    bone   nor   great    contusion   of    the 


256  A    CLINICAL    TREATISE    ON  FRACTURES. 

adjacent  soft  parts.  It  must,  however,  be  carefully  super- 
vised, and,  on  the  faintest  indication  of  its  insufficiency,  im- 
proved. Partial  excision,  which  includes  in  its  wide  scope 
the  removal  of  any  portion  of  a  joint,  from  a  small  frag- 
ment of  the  articular  surface  of  one  bone  to  almost  the 
entire  joint,  is  available  where  there  is  considerable  com- 
minution of  the  articular  surface  of  one  bone,  without  very 
serious  damage  to  the  soft  parts.  If  its  subsequent  treat- 
ment is  carefully  conducted  and  the  case  progresses  favor- 
ably, this  procedure  may  be  followed  by  excellent  restoration 
of  function.  Formal  excision  is  rarely  practised,  for  if  the 
joint  has  been  so  disorganized,  as  by  a  crush,  that  it  is 
destroyed,  conservatism  is  usually  impracticable. 

A  third  group  of  compound  fractures,  either  because  they 
cannot  be  satisfactorily  reduced,  or,  after  reduction,  will  not 
remain  in  proper  position,  are  called  refractory.  As  the 
tibia  is  by  far  the  most  common  seat  of  refractory  compound 
fracture,  upon  it  has  been  expended  more  ingenuity  than 
upon  any  other  bone  in  the  skeleton.  And  since  every  detail 
appropriate  to  its  management  applies  almost  unmodified  to 
the  femur,  humerus,  radius,  and  the  ulna,  it  may  well  be  the 
bone  selected  upon  which  to  demonstrate  the  various  means 
at  our  disposal  for  the  correction  and  management  of  such 
fractures. 

One  of  the  methods  in  most  general  use  for  the  purpose 
of  securing  apposition  of  the  fragments  is  that  of  wiring 
them  to  one  another.  After  thoroughly  cleansing  the 
wound,  removing  tissues  which  are  torn  in  such  a  way  as  to 
have  lost  their  vitality,  loose  fragments  of  bone,  clots,  etc., 


COMPOUND  FRACTURES.  257 

under  the  most  thorough  antiseptic  precautions,  the  ends  of 
the  fragments  are  perforated  with  a  bone-drill,  and  secured  in 
close  approximation  by  silver  wire  passed  through  the  open- 
ings thus  made  and  twisted.  In  addition  to  the  partial  fixa- 
tion obtained  by  such  suturing,  considerable  inflammatory 
reaction  is  produced,  causing  a  hyperplasia  in  the  osseous 
tissue.  After  such  procedure,  if  the  wound  has  not  been  too 
large,  and  has  been  capable  of  being  rendered  aseptic,  the 
integument  mav  be  sutured  and  the  wound  closed.  The 
usual  antiseptic  dressing  of  sterile  gauze  is  then  applied,  and 
the  limb  placed  in  some  splint  which  will  secure  immobility 
of  the  part ;  for  it  is  evident  that  wiring,  thus  employed, 
leaves  a  flail-like  joint  which,  while  it  prevents  the  frag- 
ments from  overlapping,  is  not  firm. 

Other  methods  looking  to  better  fixation  are  the  scarf 
joint  of  Volkmann  secured  by  pegs ;  the  adjustment  of  a 
metal  plate  to  which  the  fragments  are  attached  by  dowels 
or  screws ;  and  the  use  of  metal  screws  or  ivory  pegs  in 
various  ways  to  best  secure  coaptation  and  immobility.  The 
fault  apparent  in  them  all  is  the  want  of  precision  in  pre- 
paring the  fragments,  and  in  adjusting  them  after  prepara- 
tion. In  order  to  present  this  subject  systematically  the 
several  methods,  particularly  one  which  has  been  elaborated 
somewhat  by  me,  will  be  described  as : 

Bone-joi7iing. — The  term  joining  is  selected  on  account 
of  its  technical  significance  in  the  arts  as  applied  to  wood 
or  metal.  Two  essential  elements  are  necessary  to  a  wood 
or  metal  joint :  (a)  the  nice  fitting  of  the  ends  to  be  joined, 
and  (d)  the  fastening  of  them  by  some  uniting  medium,  as 

17 


258 


A    CLIXICAL    TREATISE    OX  FRACTURES. 


glue,  dowels,  bolts,  or  screws.  The  preparation  of  the  ends  so 
that  they  shall  fit  together  in  an  even  joint  is  called  a  scarf, 
and,  according  to  its  shape,  a  square  or  bevelled  scarf.  The 
line  of  an  oblique  fracture  is  a  surgical  illustration  of  a 
bevelled  scarf.  A  square  scarf  must  be  cut  with  a  saw;  but 
unless  the  depth  of  the  scarf  in  each  end  of  bone  is  equal 


Fig.  ii; 


Fig.  118. 


Drill-clamp. 


Rack. 

the  resulting  joint  will  not  be  firm.  An  imperfect  joint 
may  be  made  firm  by  two  screws  or  pegs ;  but  as  the  depth 
of  the  scarf  required  to  give  space  for  the  insertion  of  two 
screws  or  pegs  would  too  much  shorten  the  bone,  a  method 
will  presently  be  described  by  which  a  firm  joint  can  be 
obtained  by  the  use  of  a  single  screw,   in  cases  in  which 


COMPOUND  FRACTURES. 


259 


the  fracture  is  too  nearly  transverse  to  secure  the  fragments 
in  the  line  of  their  fracture.  For  cases  in  which  it  is 
desired  to  join  the  ends  of  bone,  I  have  devised  the  fol- 
lowing method:  As  the  ends  of  a  bone  cannot  be  sawn  or 
drilled  with  any  precision  unless  they  are  held  much  more 
firmly  than  is  possible  by  manual  support,  the  mechanical 
device  shown  in  Fig.  118  was  designed  for  this  purpose. 
It  consists  of  a  framework,  or  rack,  into  the  arm  of  which 
can  be  inserted  two  separate  clamps  ;  the  first  (in  place),  a 
simple  C-shaped  one,  in  which  the  bone  is  firmly  held  by  a 

Fig.  119. 


•Tibia  after  section  to  make  scarf-joint  (experimental). 

pointed  binding-screw  preparatary  to  being  sawn;  and  the 
second,  a  fenestrated  clamp  (Fig.  117),  which  will  hold  the 
sawn  or  fractured  fragments  together  in  firm  and  accurate 
apposition  for  drilling.  The  apparatus  is  kept  steady  by  the 
hands  of  an  assistant.  It  is  applicable  for  bone-joining  by 
any  method,  whether  used  for  compound  fracture,  ununited 
fracture,  or   faulty  union    after  fracture,  and  is  equally  ad- 


260 


A    CLINICAL    TREATISE    ON  FRACTURES. 


justable  to  all  the  long  bones  ;  for  the  principles  upon  which 
it  operates  are  simply  to  hold  firmly,  and  as  much  like  a  vise 
as  the  conditions  will  allow,  first,  the  fragment  of  bone  to 
be  sawn,  and,  second,  the  two  fragments  to  be  drilled. 
With  a  saw  to  which  a  gauge  is  attached,  which  may 
Fig.  120.  Fig.  121.  Fig.  122.  Fig.  123. 


Ivory  screw. 


Reamer. 


Screw-tap. 

be  set  at  a  half,  five- 
eighths,  or  three-quar- 
ters of  an  inch,  a  square  scarf  is  cut 
of  corresponding  depth  in  the  lower 
fragment,  which  is  held  firm  in  the 
rack  by  the  C  clamp.  Reversing  the 
gauge  to  the  opposite  side  of  the  saw, 
a  similar  scarf  is  cut  in  the  upper 
fragment,  as  shown  in  Fig.  119.  The 
joint  thus  prepared  by  scarfing  the  two  ends  is  adjusted 
and  held  firmly  together  by  the  drill  clamp  (Fig.  117), 
which  is  substituted  in  the  rack  for  the  C  clamp.  The 
drill  (Fig.  120)  is  applied  above  and  made  to  bore  through 
both  fragments.  With  the  reamer  (Fig.  121)  the  drill-hole 
in  the  lower  fragment  (which  is  above)  is  enlarged  and  the 


Drill. 


COMPOUND  FRACTURES.  26 1 

screw-tap  (Fig.  122)  made  to  cut  a  thread  in  the  upper 
fragment  (which  is  beneath).  The  ivory  screw  (Fig.  123) 
is  then  set  up  with  the  wrench  used  for  the  tap.  On 
removal  of  the  clamp  a  firm,  strong  joint  remains,  which 
readily  supports  the  weight  of  the  portion  of  the  limb 
below  it,  as  shown  in  Fig.  124.     The  same  operation  demon- 

Fig.  124. 


Tibia  united  by  single  screw  (experimental). 

strated  on  the  femur,  to  which  it  would  seem  specially 
applicable  for  ununited  fracture,  is  represented  in  Figs.  125 
and  126. 

The  following  requirements  are  therefore  met  by  this 
method  :  accurate  sections,  made  possible  with  a  gauged  saw 
and  when  the  work  is  firmly  held ;  shallow  scarfs  to  min- 
imize the  resulting  shortening  of  the  limb ;  and  fastening 
of  the  scarfed  joint  by  a  single  screw,  as  so  little  space  is 
required  for  it.  The  ivory  or  bone  bolts  should  be  sterilized 
by  prolonged  boiling,  before  the  thread  is  cut  in  them  and 
afterwards  resterilized  by  immersion  in  a  sublimate  solution, 
as  boiling  distorts  the  thread  of  the  screw. 

While  the  practice  of  surgeons  differs  regarding  the  classes 
of  compound  fractures  which  require  some  operation  in  order 
to  secure  coaptation  and  fixation  of  their  fragments  by 
mechanical   means,    probably  all    agree   that  in   most  cases 


262 


A    CLINICAL    TREATISE    OX  FRACTURES. 


in  which  the  deformity  is  sufficiently  refractory,  both  in 
resisting  reduction  and  retention  after  reduction,  operation 
is  entirely  justifiable.  Certain  it  is  that  when  compound 
fractures — and  this  statement  applies  more  to  the  tibia  than 
to  any  other  bone — require  free  incision  for  purposes  of 
cleansing  and  removal  of  the  debris,  whether  of  extraneous 
matter  or  of  comminuted  bone  and  crushed  soft  tissue,  they 
had  far  better  be  given  the  advantage  of  nice  coaptation 
and  perfect  fixation.     Skilfully  done,  no  increased  element 


Fig.  12;. 


Femur  after  section  for  scarf  joint  (experimental  1. 

of  risk  is  added  to  the  case,  and  the  danger  of  infection  is 
lessened  by  the  greatly  reduced  tendencv  to  suppuration 
always  observed  after  accurate  adjustment  and  complete 
fixation. 

Depraved  Union  after  Fracture. — Since  the  manage- 
ment of  refractory  fractures  as  just  described  is  often 
equally  applicable  for  the  correction  of  deformities  result- 
ing from  the  faulty  union  of  fractures,  the  latter  may 
properly  be  referred  to  here.  By  this  term  is  understood 
a    degree    of  deformity    after    union    is    complete   which  so 


COMPOUND   FRACTURES. 


263 


interferes  with  the  natural  function  of  the  part  as  seriously 
to  impair  or  destroy  its  usefulness.  Occurring  in  the  shaft 
of  a  bone  the  deformity  may  be  angular  or  it  may  consist 
of  overlapping  or  rotation.  Whatever  its  principal  char- 
acter, correction,  if  complete  consolidation  has  taken  place, 
can  only  be  effected  by  osteotomy  combined  at  times  with 
some  method  of  bone-joining.  If  simple  osteotomy  is  to 
be  performed,  it   should   be  done  just  as  for  correction  of 

Fig.  126. 


Femur  united  by  single  screw  (experimental). 

deformity  from  any  other  bone  defect;  but  if  it  is  intended 
to  join  the  fragments  after  division  the  section  should  be 
made  with  a  saw  instead  of  a  chisel,  and  so  planned, 
according  to  the  nature  of  the  deformity,  that  it  can  be  best 
utilized  in  forming  the  desired  joint.  Thus  if  the  frag- 
ments have  united  with  marked  overlapping,  a  very  oblique 
or  even  longitudinal  section  will  best  utilize  their  length; 
while,  if  angularity  is  the  prominent  element,  accompanied 
perhaps  with  rotation,  cross-section  may  best  prepare  them 
for  reunion. 

Faulty  union  after  fracture  which  affects  the  appearance 


264  A    CLINICAL    TREATISE    ON  FRACTURES. 

but  not  the  function  of  a  part  is,  of  course,  most  frequently 
observed  after  fracture  of  the  bones  of  the  face,  particularly 
the  nose  and  lower  jaw.  If  union  in  such  cases  has  become 
too  firm  to  yield  to  the  application  of  moderate  force,  section 
with  the  chisel  may  be  resorted  to,  but  not  without  the 
clearest  understanding  of  the  risks  it  may  involve,  and  only 
if  the  degree  of  deformity  is  so  marked  as  to  justify  such 
radical  means  for  its  correction. 

The  general  management  of  any  compound  fracture  in 
which,  owing  either  to  the  form  of  the  bone  or  to  the 
character  of  the  fracture,  the  elements  of  displacement  and 
mobility  are  wanting,  is  very  much  simplified.  With  no 
deformity,  or  deformity  which  once  corrected  remains  re- 
duced, and  with  none  of  the  requirements  of  fixation  to 
prevent  motion  at  the  seat  of  fracture,  the  treatment  is 
narrowed  down  to  the  thorough  sterilization  of  the  bone 
and  soft  parts,  the  removal  of  foreign  matter  and  loose 
fragments  of  bone  from  the  wound,  provision  for  free  drain- 
age, and  the  application  of  the  appropriate  gauze  dressing 
to  the  part. 


INDEX. 


Acetabulum,  fractures  of,  171. 
Age,  influence  of,  on  frequency  of  fract- 
ures, 9 
Allis's  sign  in  fractured  femur,  155 
Ambulatory  treatment  of  fractures,  131 
Astragalus,  fractures  of,  112 
treatment,  113 

B. 

Barker's  operation   for  fractured   patella, 

144 
Barton's  bandage  for  fracture  of  the  jaw, 

235 
bran   dressing  for  compound  fractures, 

242 
Bond's  splint,  39 

Bone-joining  after  compound  fracture,  257 
Buck's  extension  apparatus,  162 

C. 

Calcaneum,  fractures  of,  III 

treatment,  112 
Carpus,  fractures  of,  23 
Causes  of  fractures,  9 

age,  influence  of,  9 

diathetic  disease,  10 

direct  force,  10 

experimental  production,  12 

force  required  to  produce,  II 

indirect  force,  10 

muscular  force,  10 

predisposing,  9 

tensile  strain,  13 
Clavicle,  fractures  of,  98 

causes,  98 

deformity  resulting  from,  99 

Desault  dressing,  102 

diagnosis,  100 

treatment,  101 


Coccyx,  fractures  of,  200 
Coccydynia,  200 
Colles's  fracture,  34 

diagnosis,  38 

reduction,  38 

treatment,  39 
Comminuted  fractures,  16 
Complicated  fractures,  16 
Compound  fractures,  16,  238 

bone-joining,  257 

causes,  239 

complications,  243 

depraved  union  after,  262 

difficulty  in  reduction,  240 

irrigation  in  treatment  of,  254 

operative  treatment,  256 

plaster-of- Paris  dressing,  252 

refractory,  256 

suppuration  after,  241 

treatment,  248,  256 

wiring  of  fragments,  256 

D. 

Delayed  union,  20 
treatment,  21 
Depraved  union  after  compound  fracture, 

262 
Desault  dressing  for  fractured  clavicle,  102 
Diathetic  disease  in  relation  to  fractures,  10 

E. 

Experiments  in  the  force  required  to  pro- 
duce fractures,  12 


Face,  fractures  of  the  bones  of,  228 
Fat-embolism  after  compound  fracture,  247 
Femur,  fractures  of,  147 

Allis's  sign,  155 

experimental  production,  13 
265 


266 


INDEX. 


Femur,  fractures  of,  Nelaton's  sign,  154 
of  the  lower  extremity,  156 
causes,  157 
diagnosis,  158 
treatment,  167 
varieties,  156 
of  the  shaft,  148 
causes,  148 
diagnosis,  150 
treatment,  162 
varieties,  148 
of  the  upper  extremity,  152 
causes,  153 
diagnosis,  153 
treatment,  165 
varieties,  152 
treatment,  general  considerations,  160 
Fibula,  fractures  of,  118 

accompanying  fracture  of  tibia,  122 
deformity,  126 
diagnosis,  121 
Pott's  fracture,  119 
treatment,  124 
Fissured  fracture,  16 
Fixation  of  fragments,  23 
Force  required  to   produce   fracture,  ex- 
perimental estimation  of,  12 
varieties,  II 
Forearm,  fractures  of  both  bones,  61 
diagnosis,  65 
treatment,  65 

G. 

Gangrene   following   compound   fracture, 

248 
Gibson's  bandage,  236 
Green-stick  fracture,  24 
Gunshot  fractures,  19 

H. 

Humerus,  fractures  of,  67 

experimental  estimation  of  force  re- 
quired to  fracture,  13 
of  the  lower  end,  68 
causes,  69 
diagnosis,  70 


Humerus,    fractures    of    the    lower  end, 
treatment,  72 
varieties,  68 
of  the  shaft,  77 
causes,  77 
diagnosis,  79 
treatment,  80 
varieties,  78 
of  the  upper  extremity,  83 
anatomical  neck,  86 
causes,  84 
diagnosis,  84 
epiphyseal  separation,  88 
non-union  after,  92 
surgical  neck,  85 
treatment,  88 
tuberosities,  88 
varieties,  83 
Hyoid  bone,  fracture  of,  237 

I. 

Ilium,  fractures  of,  169 

Indian  puzzle  apparatus  for  fractured 
patella,  141 

Irrigation  apparatus  for  compound  fract- 
ures, 254 

Ischium,  fractures  of,  170 

J- 

Jaws,  fractures  of  (see  Maxilla),  230,  232 

L. 

Leg,  fractures  of  (see  also  Tibia  and  Fibula), 
114 
both  bones,  122 
treatment,  124 
Lever  and  fulcrum  for  use  in  fracture  of 

skull,  220 
Lower  jaw,  fractures  of  (see  Maxilla),  232 
Liston's  long  splint   for  fractured  femur, 
164 

M. 
Malar  bone,  fractures  of,  231 
Malgaigne's  hooks,  140 
Maxilla,  fractures  of,  superior,  230 
inferior,  232 


IXDEX. 


267 


Measure   of    force    required    to    produce 

fractures,  II 
Metacarpus,  fractures  of,  28 

treatment,  32 
Metatarsus,  fractures  of,  107 

treatment,  109 
Multiple  fractures,  16 
Muscular  force,  fracture  by,  10 


N. 


Nose,  fracture  of,  228 


O. 

Operation  for  ununited  fracture,  22 
Os  calcis,  fractures  of,  III 


Patella,  fractures  of,  131 

Barker's  operation,  144 

causes,  132 

diagnosis,  135 

experimental  production,  13,  132 

Indian  puzzle  apparatus,  141 

non-operative  treatment,  139 

operative  treatment,  138,  144 

Stimson's  operation,  145 

subcutaneous  operation  for,  144 

treatment,  137 

varieties,  134 
Pelvis,  fractures  of,  169 

acetabulum,  171 

ilium,  169 

ischium,  171 

pubis,  170 

treatment,  172 
Phalanges,  fractures  of,  fingers,  25 

toes,  106 
Plaster-of- Paris   dressing  for  leg  fractures 
126 
jacket  in  fractures  of  the  spine,  195 
Pott's  fracture,  1 18 
Predisposing  causes  of  fracture,  9 
Pubis,  fractures  of,  170 
Punctured  fractures,  16 


R. 

Radius,  fractures  of,  ^ 

Bond  splint,  39 

Colles's  fracture,  34 

diagnosis,  38,  45 

lower  extremity,  33, 

shaft,  44 

silver-fork  deformity,  34 

treatment,  39,  46,  51 

upper  extremity,  49 
Reduction  of  fractures,  23 
Refractory  fractures,  23 
Ribs,  fractures  of,  176 

complications,  179 

diagnosis,  178 

treatment,  180 
Riehle  testing-machines,  12 
Rongeur  forceps  (spinal),  196 

S. 

Sacrum,  fractures  of,  200 
Scapula,  fractures  of,  94 

acromion  process,  96 

body,  94 

coracoid  process,  95 

treatment,  97 
Scarf-joint  for  ununited  fractures,  259 
Simple  fractures,  15 
Skull,  fractures  of,  201 

base,  204 

cerebral  symptoms,  208 

diagnosis,  210 

lever    and    fulcrum    to  elevate  frag- 
ments, 220 

prognosis,  213 

sequelse,  224 

treatment,  214 

varieties,  206 
Smith's  anterior  splint  for  fractured  femur, 

164 
Spine,  fractures  of,  182 

bodies  of  vertebrse,  191 

causes,  184 

coccyx,  200 

diagnosis,  183 

laminae,  189 


268 


IXDEX. 


Spine,   fractures   of,    non-operative   treat- 
ment, 193 

operative  treatment,  196 

sacrum,  200 

spinous  processes.  1S8 

symptoms,  186 
Sternum,  fractures  of,  174 

diagnosis,  175 

treatment,  175 


Tarsus,  fractures  of,  109 

astragalus,  1 1 2 

diagnosis.  Ill 

os  calcis.  1 1 1 

treatment,  112 
Tenotomy  of  tendo  Achillis  in  fractures 

of  leg,  127 
Tetanus  after  compound  fractures,  246 
Tibia,  fractures  of,  114 

accompanying  fracture  of  fibula,  122 

diagnosis,  1 16 

lower  extremity,  1 14 

shaft,  114 

treatment,  124 

upper  extremity.  117 
Trephining  forceps  for  fracture  of  skull, 
217 


U. 
Ulna,  fractures  of,  51 

coronoid  process,  58 

diagnosis,  51,  54,  55,  58 

olecranon  process,  55 

shaft,  52 

styloid  process,  51 

treatment,  52,  55,  56,  59 
Ununited  fracture,  20 

treatment,  21 
Upper  jaw,  fractures  of  [see  Maxilla),  23c 


Varieties  of  fracture,  16 
Velpeau  bandage.  97 
Vertebrae,  fractures  of,  182 

bodies,  1 91 

causes,  184 

coccyx,  200 

laminae,  189 

non-operative  treatment,  193 

operative  treatment,  196 

sacrum,  200 

spinous  processes,  iSS 

symptoms,  186 

treatment,  193 

Z. 

Zygoma,  fractures  of,  232 


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